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Cduntbia  ^tttbei^siti) 


(gift  of  ir.  3lo0?pt|  A.  llakr 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/operativesurgeryOObrya 


OPERATIVE    SURGERY 


BY 

JOSEPH    D.   BRYANT,   M.  D. 

Professor  of  the  Principles  and  Practice  of  Surgerj-,  Operative  and  Clinical  Surgery,   University 
and    Bellevue  Hospital   Medical   College;    Visiting  Surgeon  to   Bellevue  and   St.  Vincent's 
Hospitals ;  Consulting  Surgeon  to  the  Hospital  for  Ruptured  and  Crippled,  Woman's 
Hospital,    and    Manhattan    State    Hospital    for    the    Insane;     former    Surgeon- 
General  of  N.  G.  N.  Y.  ;    Fellow  of  the  American   Surgical  Association; 
Member  of  the  International  Society  of  Surgeons,  and  of  the  Ameri- 
can Medical  Association  ;   former  President  of  the  New  York 
Academy  of  Medicine,  and  of  the  New  York  State 
Medical  Association  ;   President  of  the  New 
York  State  Medical  Society,  etc. 


Volume  I 

GENERAL  PRINCIPLES,  AN/ESTHETICS,  ANTISEPTICS,  CONTROL 
OF  HytMORRHAGE  AND  SHOCK.  TREATMENT  OF  OPERA- 
TION-WOUNDS, LIGATURE  OF  ARTERIES.  OPERATIONS  ON 
VEINS,  CAPILLARIES,  NERVOUS  SYSTEM,  TENDONS,  LIGA- 
MENTS, FASCI/t,  MUSCLES,  BURS/t,  AND  BONES.  AMPUTA- 
TIONS, DEFORMITIES.  PLASTIC  SURGERY.  OPERATIONS  ON 
MOUTH,    PHARYNX,    NOSE,    CESOPHAGUS,    AND    NECK 


Fourth  Edition,  Printed  from  New  Plates 
Entirely  Revised  and  Largely  Rewritten 


THIS   VOLUME    CONTAINS 

EIGHT  HUNDRED  AND  NINETY-EIGHT  ILLUSTRATIONS 

SIXTY-ONE    OF    WHICH  ARE    COLORED 


NEW    YORK    AND    LONDON 

D.    APPLETON     AND    COMPANY 

1905 


-( 


V 


Copyright,  1886,  1899,  1905, 
By  D.  APPLETON  AND   COMPANY 

All  rights  reserved 


PRINTED   AT   THE  APPLETON  PRESS 
NEW   YORK,    U.    S.    A. 


TO 

THE   GEADUATES  IN   MEDICINE 

WHOM    IT   HAS   BEEN   MY   PLEASURE   TO   INSTRUCT   IN   ANATOMY  AND 

SURGERY  DURING   THE    LAST   TWENTY-FIVE  YEARS, 

AND   IN   RECOGNITION   OF 

THE   UNIFORM   COURTESY   SHOWN   BY   THEM   TO   THE   AUTHOR, 

THIS  WORK  IS  RESPECTFULLY  INSCRIBED 


PEEFACE  TO   FOURTH  EDITION. 


The  rapid  absorption  of  the  repeated  issues  of  the  third  edition,  the 
warmth  of  the  commendations  bestowed  upon  it,  the  accelerated  pace  of 
surgery  in  various  respects  and  the  repeated  requests  of  many  whose 
support  and  friendship  the  author  holds  in  high  esteem,  have  hastened 
the  preparation  of  the  fourth  edition.  This  edition  contains  about  two 
hundred  and  fifty  pages  and  two  hundred  and  thirty  illustrations  more 
than  the  preceding  one.  It  has  been  entirely  revised,  much  of  it  rewritten, 
and  new  matter  introduced.  As  in  the  preceding  editions,  earnest  efforts 
are  made  to  give  due  credit  to  those  whose  labors  have  added  interest  and 
usefulness  to  its  pages,  and  any  failure  to  do  so  is  the  result  of  inad- 
vertence, not  of  intent.  The  author  begs  to  express  his  great  indebted- 
ness to  Prof.  William  C.  Lusk,  M.  D.,  for  the  revision  and  advancement 
of  the  chapter  on  the  rectum  ;  to  Prof.  Hermann  A.  Haubold,  M.  D.,  for 
his  painstaking  search  for  items  adding  renewed  usefulness  to  "  The  Re- 
sults "  ;  to  Dr.  William  M.  Ford  for  the  thorough  index  so  patiently 
prepared ;  and  also  to  Dr.  Thomas  L.  Bennett,  an  anaesthetist  of  broad 
experience,  to  whom  we  are  lai'gely  indebted  for  the  practical  considera- 
tions given  to  ansesthesia.  The  artists,  the  artisans,  and  the  publishers 
have  vied  with  each  other  in  enhancing  the  value  of  the  products  of  the 
author's  labors.  With  profound  thanks  to  the  members  of  the  profes- 
sion for  the  evidences  of  appreciation  so  freely  bestowed  on  the  past  edi- 
tions, the  author  humbly  submits  the  present  one  for  such  consideration 
as  it  may  justly  merit. 

Joseph  D.  Bkyant,  M.  D. 

33  West  Forty-eighth  Street,  New  York. 


PREFACE  TO   THIRD   EDITIOK 


The  flattering  reception  of  the  second  edition,  and  the  requests  of 
many  interested  friends  that  a  third  be  written,  prompted  me  about 
four  years  ago  to  begin  the  task.  But  the  frequent  and  somewhat 
extended  interruptions  begotten  of  the  demands  of  life's  activities, 
together  with  the  determination  to  extend  the  scope  and  size  of  the  work, 
have  unexpectedly  delayed  its  publication.  Besides,  the  rapid  advance  in 
the  last  few  years  of  surgical  endeavor  has  greatly  increased  the  amount 
and  complicated  the  character  of  the  labor  required  for  the  purpose. 
The  general  policy  of  arrangement  of  the  work  is  maintained,  and,  as  in 
the  past,  frequent  references  are  made  to  the  labors  and  sayings  of 
others,  to  all  of  which  credit  is  given  in  the  text  or  in  the  index.  Special 
effort  is  made  to  eliminate  from  the  faces  of  the  illustrations  all  evidences 
suggestive  of  commercial  thrift.  Much  is  gained  in  this  respect  by  the 
introduction  of  half-tone  groups  of  instruments  and  by  the  gracious 
co-operation  of  Mr.  Ford.  An  index  of  illustrations,  in  which  due  credit 
is  given  to  all,  is  introduced.  The  operations  peculiar  to  the  female  sex, 
and  of  the  eye  and  ear,  are  omitted  in  this,  as  in  the  preceding  editions, 
and  for  similar  reasons.  The  valuable  services  of  Professors  George  D. 
Stewart  and  William  C.  Lusk,  in  connection  with  proof  reading  and 
indexing,  are  especially  painstaking,  and  are  gratefully  acknowledged. 
The  artists,  Messrs.  Mason  (photographer  to  Bellevue  Hospital)  and 
Senior,  vied  with  each  other  in  their  efforts  to  produce  proper  illustrative 
effects.  In  conclusion,  it  is  hoped  and  believed  that  the  reader  will  find 
in  the  following  pages  sufiicient  of  interest  and  importance  to  justify  the 
use  of  the  time  employed  by  himself  and  the  author  in  their  consideration. 

Joseph  D.  Bkyant,  M.D. 

54  West  Thirty-sixth  Street,  New  York. 
vi 


PEEFACE  TO   SECOND  EDITION. 


The  frequent  request  on  the  part  of  those  whom  it  has  been  my 
pleasure  to  instruct  in  operative  surgery  during  the  past  few  years,  to 
make  a  book  based  somewhat  on  the  plan  I  have  employed  in  teaching  this 
subject,  is  the  principal  incentive  to  my  action.  The  field  of  operative 
surgery  is  too  well  cultivated  already  for  one  to  do  more  in  this  brief 
space  than  aid  the  student  of  surgery  to  acquire  established  facts.  The 
works  of  Ashhurst,  Agnew,  Gross,  Erichsen,  Holmes,  Smith,  Esmarch, 
Packard,  Stimson,  and  many  others,  together  with  the  current  medical 
literature,  have  been  consulted.  The  illustrations,  which  are  numerous, 
have  been  selected  in  most  instances  from  standard  works,  although  a 
considerable  number  of  original  and  modified  illustrations  have  been 
introduced.  Mr.  W.  F.  Ford,  of  the  reputable  firm  of  Caswell,  Hazard 
&  Co.,  of  this  city,  kindly  provided  the  instrumental  cuts,  as  is  to  be  seen 
by  the  Index  of  Illustrations.  The  author  desires  to  acknowledge  the 
aid  derived  from  the  above-mentioned  sources,  and  trusts  the  reader  will 
find  something  to  commend  in  the  pages  that  are  to  follow.  The  author 
regrets  that  sufficient  data  are  not  at  hand  to  permit  the  "  results "  to 
be  given  in  all  instances  as  modified  by  the  antiseptic  method  of  treat- 
ment. The  operations  peculiar  to  the  female  sex,  and  the  eye  and  ear, 
have  not  been  considered,  since  they  are  entitled,  in  the  opinion  of  the 
author,  to  a  more  extended  consideration  than  the  intentional  scope  of 
this  work  will  admit.  The  author  desires  to  acknowledge  the  valuable 
services  of  Drs.  Glover,  C.  Arnold,  and  Hermann  M.  Biggs,  in  connection 
with  the  proof  reading,  and  of  Dr.  Arnold  also  for  the  complete  indices 
of  the  book.  The  assistance  of  Dr.  A.  H.  Doty  in  preparing  many  of  the 
original  illustrations  is  likewise  gratefully  acknowledged. 

Joseph  D.  Bryant,  M.  D. 

66  West  Thirty-fifth  Street,  New  York. 


CONTENTS  OF   VOLUME   I. 


CHAPTER   I. 

THE   GENERAL    CONSIDERATIONS. 

Definition  of  operative  surgery— Facts  to  be  ascertained  before  operating— Time 
for  operation— Place  for  operation— Sick-room— Nursing— Diet— Require- 
ments relating  to  operations— How  to  prepare  patient  for  antesthesia- How 
prepare  administrator  of  anaesthetic— Treatment  of  ana-sthetic  poison— Dan- 
gers of  use  of  anipsthetic— Inhalers— Chloroform— A.  C.  E.  mixture— Nitrous 
oxide— Gas  and  oxygen— Morphine  with  anaesthetics- Moderate  inebriation- 
Oxygen  anaesthesia- Rapid  respiration— Local  ansesthesia— Infiltration  an- 
esthesia-Spinal anaesthesia— Cocain—Eucain— Instruments  necessary  for 
operations— Methods  of  holding  scalpel— Blunt  dissection— Incisions— Anti- 
septic and  aseptic  methods— Operating  tables— Aseptic  and  antiseptic  solu- 
tions— Sponges — ^Wipers,  etc. 

CHAPTER   II. 

AGENTS    FOR   THE    CONTROL   OF   HEMORRHAGE. 

Artificial  haemostatics  —  Styptics  —  Position  —  Bandages  —  Compresses  —  Digital 
pressure  — Tourniquets  — Davy's  lever  —  Trendelenburg's  rod- Wyeth's 
method  —  Torsion  —  Forceps  —  Forcipressure— Cautery  —  Ligatures  —  How 
made— How  tied— Assistants— Preparation  of  patient— Preparation  of  field 
of  operation     ...••••••••"" 

CHAPTER    III. 

THE    TREATMENT    OF    OPERATION-WOUNDS. 

Sutures— Needles— Needle-holders— Various  forms  of  sutures— Drainage  tubes- 
Catgut  drainage— Canalization— Protective  dressings— Antiseptic  douche- 
Antiseptic  dressings— Objections  to  use  of  iodoform— Objections  to  bichloride 
gauze— Common  preparations  for  a  modern  operation— Diagram  of  arrange- 
ments—Open dressing— Precautionary  requirements  of  operations— Special 
emergencies  of  operations 

CHAPTER    IV. 

THE   LIGATURE    OF   ARTERIES. GENERAL    CONSIDERATIONS. 

Guides  to  ligaturing— Making  primary  incision— Opening  sheath  of  a  vessel-- 
Passing  ligature— Instruments  required  for  ligaturing— Ligature  of  abdominal 
aorta— Of  common  iliac  artery— Of  internal  iliac  artery— Of  gluteal  artery— 
Of  pudic  artery— Of  dorsalis  penis  artery— Of  external  iliac  artery— Of  deep 
epigastric  artery— Of  deep  circumflex  iliac  artery— Of  superficial  lemoral 
artery— Of  deep  femoral  artery— Of  external  circumflex  artery— Of  popliteal 


65 


96 


X  CONTENTS  OF  VOLUME   I. 

PAGE 

artery — Of  anterior  tibial  artery — Of  dorsalis  pedis  artery — Of  posterior 
tibial  artery — Of  peroneal  artery — Of  innominate  artery — Of  subclavian 
arteries — Of  internal  mammary  artery — Of  inferior  thyroid  artery — Of  axillary 
artery — Of  brachial  artery — Of  radial  and  ulnar  arteries — Of  palmar  arteries — 
Of  coinmon  carotid  artery — Of  both  common  carotid  arteries — Of  the  com- 
mon carotid  artery — -Temporary  ligature  of  common  carotid — Ligature  of  the 
internal  carotid — Of  the  superior  thyroid  artery — Of  the  lingual  artery — Of 
the  facial  artery — Of  the  temporal  artery — Of  the  occipital  artery- — ^Extir- 
pation of  aneurism — Radical  cause  of  aneurism — -Arteriorrhaphy — Phleb- 
orrhaphy.        .............     125 

CHAPTER    V. 

OPERATIONS    ON    VEINS,    CAPILLARIES,    ETC. 

Ligature  of  veins — Operations  for  varicose  veins — Injection — Acupressure — Sub- 
cutaneous ligaturing  —  Excision  —  Venesection  —  Transfusion  — -  With  saline 
solution — Mother's  mark,  treatment  of — Nsevi,  treatment  of — Cirsoid  growths, 
treatment  of    .         .         .         .         .         .         .         .         .         .         .         .         .     215 

CHAPTER    VI. 

OPERATIONS    ON   THE   NERVOUS    SYSTEM. 

Operations  for  chronic  hydrocephalus — For  acute  hydrocephalus — For  meningo- 
cele— For  encephalocele — Craniotomy,  instruments  employed  in — Important 
considerations  in — ^Craniotomy  in  meningeal  haemorrhage — For  microcephalus 
For  cerebral  tumor,  instruments  employed  in — Craniotomy  for  epilepsy— For 
evacuation  of  pus — For  cerebellar  tumor — For  thrombosis  of  lateral  sinus  and 
jugular  vein — For  general  paralysis  of  the  insane — Opening  the  mastoid  an- 
trum, instruments  employed  in — Trephining  the  frontal  sinus — Gunshot 
wounds  of  the  cranium — Location  of  the  missile — ^The  precautions — ^The 
results. 

Special  operations  on  nerves — Nerve  section  or  neurotomy — Nerve  resection  or 
neurectomy — Nerve  stretching  or  neurectosy — Suture  or  neurorrhaphy — 
Nerve  grafting  or  neuroplasty — The  methods  of  practice — The  results. 

Operations  on  special  nerves — Operations  on  supra-orbital  nerve — On  supra- 
trochlear nerve — On  infra-orbital  nerve — On  superior  maxillary  nerve — On 
Meckel's  ganglion — On  inferior  dental  nerve — On  lingual  nerve — ^On  gusta- 
tory nerve — On  auriculo-temporal  nerve — On  buccal  nerve — On  trunk  at  the 
foramen  ovale. 

Intracranial  neurectomy,  instruments  employed  in — Rose  method — Hartley- 
Krause  method  —  Stages  of  —  Precautions  —  Complications  —  Results  and 
sequels — Doyen's  method — Cushing's  method — Abbe's  method — -Spiller  and 
Frazer  method — Horsley's  intradural  method — Operations  on  the  facial  nerve 
— Cushing's  for  paralysis. 

Operations  on  the  spinal  cord  and  spinal  nerves — Laminectomy,  instruments  em- 
ployed in — Examination  of  the  contents  of  the  canal — Opening  of  the  dura — 
Results — Operation  of  spinal  meningeal  drainage — Parkin's  operation — 
Spina  bifida,  operations  for — Injection — Excision — Meningocele,  operations 
for — Meningo-myelocele,  operations  for — Tumors  of  the  spinal  cord — The 
operation  for — The  results — Spinal  accessory  nerve,  operations  on — Branches 
of  the  cervical  nerves,  operations  on — Roots  of  the  spinal  nerves — Intraspinal, 
division  of — Branches  of  the  brachial  plexus,  operations  on— On  musculo- 


CONTENTS  OF   VOLUME  I.  xi 


PAGE 


cutaneous  nerve— On  musculo-spiral  nerve— On  circumflex  nerve— On  median 
nerve— On  ulnar  nerve— Branches  of  the  sacral  plexus,  operations  on— On 
great  sciatic  nerve— On  internal  popliteal  nerve— On  external  popliteal  nerve 
—On  plantar  nerves— On  brachial  nerves— On  tibial  nerve,  etc.— Branches  of 
the  lumbar  plexus,  operations  on— On  anterior  crural  nerve— On  obturator 
nerve— On  long  saphenous  nerve— On  short  saphenous  nerve  .         .         .         .227 

CHAPTER    VII. 

OPERATIONS    ON    TENDONS,    LIGAMENTS,    FASCIAS,    MUSCLES,    AND    BURS-E. 

Tenotomy,  instruments  employed  in— Rules  for— Tenotomy  of  tendons  of  flexor 
sublimis  and  flexor  profundus  digitorum  muscles— Of  extensor  communis 
digitorum  muscle— Of  extensor  brevis  longus  and  ossis  metacarpi  pollicis 
muscles— Of  flexor  carpi  radialis  muscle— Of  flexor  carpi  uhiaris  muscle— Of 
the  biceps  muscle  of  the  forearm,  etc.— Of  the  tibialis  posticus  muscle— Of  the 
flexor  longus  digitorum  muscle— Of  flexor  longus  pollicis  muscle— Of  tendo 
Achillis— Of  peroneus  longus  and  brevis  muscles— Of  til)ialis  anticus  muscle— 
Of  extensor  proprius  pollicis  muscle— Of  extensor  longus  digitorum  muscle— 
Of  peroneus  tertius  muscle— Of  hamstring  tendons— Of  gracilis  and  sartorius 
muscles— Of  quadriceps  extensor— Of  adductor  longus  muscle. 

Myotomy— Of  pectineus  muscle— Of  tensor  vaginte  femoris  muscle— Of  multifidus 
spina^  muscle— Of  latissimus  dorsi  muscle— Of  erector  spinas  muscle— Of 
trapezius  muscle — Of  sterno-mastoid  muscle,  etc. 

Tenorrhaphy,  special  considerations  in— Tendon  lengthening— Tendon  shortening 
— Tendon  transplantation — The  results. 

Myotomy,  oblique  division  in— V-shaped  division  in— Syndesmotomy-Fasci- 
otomy— Dupuytren's  contraction,  treatment  of— Bursa>,  treatment  of— The- 
citis,  treatment  of 

CHAPTER    VIII. 

OPERATIONS    ON    BONES. 

Gouging,  instruments  employed  in— Schede's  method  of  heaUAg-^equestrotomy, 
instruments  employed  in— Excisions  of  extremities,  instruments  employed  m 
—Treatment  of  excision  wounds— Excision  of  upper  jaw,  mstruments  em- 
ployed in— Partial  and  complete  excision— The  lines  of  incision— Removal 
below  the  floor  of  the  orbit— Various  methods  of  practice— After-treatment- 
Results— Excision  of  lower  jaw- Anatomical  considerations— Remarks- 
Excision  of  central  portion-Of  a  lateral  portion-Of  lateral  half-Of  alveolar 
process— Immobility  of  inferior  maxilla,  operations  for— Excision  of  sternum 
—Excision  of  clavicle— Excision  of  entire  scapula— Excision  of  body  of  the 
scapula-Excision  of  glenoid  angle  of  scapula-Subperiosteal  excision  of 
scapula— Remarks— After-treatment— Results— Excision  of  humerus— Ex- 
cision of  upper  end— Subperiosteal  excision  of  head— Senn's  method— 
Kocher's  method— Arthrotomy  for  irreducible  dislocations— Operation  for 
habitual  dislocation— Excision  of  shaft— Excision  of  lower  extremity— After- 
treatment— Results— Excision  of  elbow  joint— Anatomical  pomts— Huters 
method— Langenbeck's  method— Lister's  method— Ollier's  method— After- 
treatment-Results-Excision  of  ulna-Excision  of  radius-Excision  of 
lower  extremities  of  bones  of  forearm— Excision  of  wrist  joint— Langenbeck  s 
method— Ollier's  method— Lister's  method,  etc.— Precautions-After-treat- 
ment—Results— Excision  of  metacarpo-phalangeal  joints— Excision  of  phalan- 


329 


xu 


CONTENTS   OF   VOLUME   I. 


PAGE 

geal  joints — Excision  of  phalangeal  joints  of  tarsus — Of  metacarpo-phalangeal 
joints — Of  tarso-metatarsal  joints — Of  dorsal  joints — Of  calcaneum — Of  as- 
tragalus— Excisions  of  ankle  joint — Langenbeck's  method — Bush's  method, 
gtc.  — Comments — After-treatment — Results — Wladimirow-Mikulicz  opera- 
tion— Excision  of  bones  of  leg — Excision  of  knee  joint — Anatomical  points — 
Mackenzie's  method — Bird's  method — Langenbeck's  method — OUier's  method 
Remarks — After-treatment — Results. 

Arthrectomy — Of  knee — Of  ankle — -Results — Excision  of  patella — Excision  of 
great  trochanter — Excisions  of  hip  joint — Anatomical  points — Langenbeck's 
method — Barker's  method — Sayre's  method — General  remarks — After-treat- 
ment— Results — Arthrotomy  for  old  unreduced  and  irreducible  dislocations 
of  hip — Excision  of  coccyx. 

Osteotomy,  instruments  employed  in — Comments — Subcutaneous  division  of  the 
neck  of  femur — With  saw — ^With  chisel — Volkmann's  method — Sayre's 
method — Congenital  displacements  of  hip — Hoffa's  operation — Lorenz's  mod- 
ification of — Remarks — ^Results — Bony  anchylosis  of  knee  joint — Linear 
osteotomy  in — Cuneiform  osteotomy  in — General  remarks. 

Genu  valgum — Anatomical  points — Macewen's  method  of  treatment — Results — 
Ogston's  method — Reeves's  method — Chiene's  method. 

Genu  varum — Linear  osteotomy  in — Cuneiform  osteotomy  in — Hallux  valgus — • 
Methods  of  treatment  of — Osteotomy  for  talipes — Davies-CoUey  method — 
Bradford's  method — Phelps's  open-incision  method — Enucleation  of  astraga- 
lus, etc. 

Osteoplasty — Preparation  of  bone — Preparation  of  cavity — Filling  of  cavity  and 

treatment  of  wound        ...........     356 

CHAPTER    IX. 

AMPUTATIONS.-^ — GENERAL    CONSIDERATIONS. 

General  considerations — Serviceable  stump — Proper  lengths  of  flaps — Division  of 
tissues — Classification  of  flaps — Instruments  employed  in  amputation — Com- 
parative merits  of  different  flaps — Periosteal  flap — Manner  of  grasping  ampu- 
tating knife — Of  carrying  it  around  limb — Sawing  the  bone — Use  of  retractors 
— Metal  retractor — Catching  and  tying  bleeding  points. 

Amputations  of  upper  extremities — General  remarks — Amputation  at  phalangeal 
articulations — Conservatism  illustrated — At  metacarpo-phalangeal  articu- 
lations— Amputation  of  thumb — Of  little  and  index  fingers — Amputation 
through  metacarpal  bone — Amputation  of  last  four  metacarpal  bones — ^Am- 
putation of  inner  three  metacarpal  bones — Amputation  of  four  metacarpal 
bones  with  fingers — Amputations  at  wrist  joint — Circular-flap  method — Single 
palmar-flap  method — Double-flap  method — Radial-flap  method — Remarks — 
Results — Amputations  at  forearm — Circular  skin-flap  method — Equilateral 
skin-flap  method — Musculo-cutaneous-flap  method — Comments — Results — 
Amputation  at  the  elbow  joint — Anatomical  points — Elliptical-flap  method 
— Circular  method — Anterior  single-flap  method — Comments — Results- 
Amputations  of  arm — Circular-flap  method — Irregular  double-flap  method — 
Antero-posterior-flap  method — Long  anterior-  and  small  posterior-flap  method 
Teal's  method — Amputations  at  surgical  neck  of  humerus — Anatomical  points 
— Oval  method — Single  external-flap  method — Remarks — Results — ^Amputa- 
tions  at  shoulder  joint — External-  and  internal-flap  method — Circular  method 
— Racquet  methods  of  Larrey  and  Spence — Wyeth's  method  of  prevention 
of  haemorrhage  in — Remarks — Results — Amputation  above  shoulder  joint — 
Results 451 


CONTENTS  OP  VOLUME  I.  xiii 

CHAPTER   X. 

AMPUTATION    AT   THE   LOWER   EXTREMITY. 

rA<;E 

Amputation  of  phalanges  of  toes — Amputation  of  first  phalanx  of  great  toe — Of 
last  phalanx  of  great  toe — Amputation  of  single  toes — Of  great  and  little  toes 
— By  single-flap  method — By  oval-flap  method — By  internal  plantar-flap 
method — Amputation  of  two  adjoining  toes — Of  all  toes  at  metatarso-pha- 
langeal  joints — Amputations  of  metatarsal  bones — Amputation  through  all 
these  bones — Of  great  toe  and  metatarsal  bone — (Jf  little  toe  and  metatarsal 
bone — Of  whole  or  part  of  metatarsal  bone — Lisfranc's  amputation — Re- 
marks—  Modifications  of  —  Chopart's  amputation  —  Remarks  —  Results  — 
Forbes's  modification  of — Irregular  tarsal  amputation — De  Lignerolles's  am- 
putation— Verneuil's  amputation — Hancock's  operation — -Tripier's  operation 
— Amputations  at  ankle  joint — Syme's  method — Modifications  of — Fallacies 
in — Results — Roux's  method — Pirogoff's  operation — Remarks — -Results — 
Fergusson's  modification  of — Le  Fort's  modification  of — Briins's  modifica- 
tion of — Esmarch's  modification  of  Le  Fort — Amputations  at  leg — Ampu- 
tation of  leg  at  lower  third — Guyon's  method — Duval's  method — Author's 
method  —  Teale's  method  —  Large  posterior-flap  method  —  Bilateral-flap 
method — Hood-flap  method — Amputation  of  leg  at  middle  third — By  large 
posterior-flap  method — By  long  external-flap  method — Amputation  of  leg 
at  upper  third — By  long  external-flap  method — By  circular-flap  method — By 
bilateral-flap  method — Amputations  at  knee  joint — Anatomical  points — 
Amputation  by  bilateral-flap  method — By  elliptical-flap  method — By  cir- 
cular-flap method — By  long  anterior-flap  method — S.  Smith's  amputation  at 
knee  joint  for  gangrene  of  toes  and  foot — Amputation  of  thigh  through  con- 
dyles by  Garden's  method — By  Gritti's  method — Bier  and  Eiselsberg's  method 
— -Bier's  method — By  Sabanwjeff's  method — Amputations  of  thigh — Special 
considerations — Amputation  by  equilateral-flap  method — By  bilateral-flap 
method  —  By  antero-posterior  musculo-integumentary-flap  method  —  By 
circular  integumentary-flap  method — By  high  circular-incision  method — By 
long  anterior-flap  method — By  long  antero-posterior-flap  methods — General 
remarks — After-treatment — Results — Amputations  at  hip — Methods  of  con- 
trol of  haemorrhage  in — Pancoast's,  Esmarch's,  and  Lister's  tourniquets — 
Trendelenburg's  rod — Da\'y's  lever — Brandis's  method — Wyeth's  method — 
McBurney's  method — Senn's  method — Amputation  at  hip  by  external- 
racquet  method — By  anterior-racquet  method — By  long  anterior-  and  short 
posterior-flap  methods — By  circular-flap  method — By  Furneaux  Jordan 
method — By  antero-posterior-flap  method — By  single-flap  method — After- 
treatment — -Results.        ...........     496 

CHAPTER  XI. 

DEFORMITIES. 

Congenital  or  acquired — Brisement  force  in  anchylosis — Barton's  operation  in 
anchylosis — Curvature  of  the  spine — Sayre's  apparatus  for — Deformities  de- 
pendent upon  perverse  muscular  action — Torticollis,  treatment  of — Hammer- 
toe, treatment  of — Snap  finger,  treatment  of — Deformities  due  to  fusion — 
Polydactylism — Syndactylism — The  various  methods  of  treatment — Diday's 
method — Agnew's  method — Zeller's  method — Fowler's  method,  etc. — In- 
grown toe  nail — ^The  operation  for — Anger's  method — Cotting's  method — 
Dowd's  experience — Bunion,  complications  and  treatment  of     .         .         .     558 


xiv  CONTENTS  OF  VOLUME  I. 

CHAPTER  XII. 

PLASTIC   SURGERY. 

PAGE 

Definition  of — ^The  preparation  of  patient — Size  of  flap — Instruments  employed 
in — Methods  of  practice  in — Sliding  in  direct  line — Four  varieties  of — Sliding 
in  curved  line — Dieffenbach's  methods — Burow's  methods — Jaesche-Dieff en- 
bach's  method — Littenneur's  method — -Bruns's  method — ^Weber's  method — 
Jumping — Pedicle  not  twisted — Pedicle  much  twisted — Inversion — Eversion 
— Tagliacotian  operation — -Grafting — With  heteroplastic  substances — Skin 
grafting — Reverdin's  method — Thiersch's  method — Krause's  method — Lusk's 
method — Croft's  operation  for  cicatricial  contraction — Flaps  with  single  and 
double  pedicles — Rhinoplasty — the  French  method — Syme's  operation — 
EUis's  method — Langenbeck's  method — Denonvillier's  method — Buck's 
method — Repair  of  columna — Dieffenbach's  method  of  restoration  of  nose — 
Verneuil's  method — Indian  method — Thiersch's  method — Langenbeck's  and 
OUier's  method — Triangular  flap  in — Dieffenbach's  flap  in — Langenbeck's 
flap  in — Keegan's  method — Italian  method — Osteoplasty — Rhinoplasty — 
OUier's  method — Konig's  method — Israel's  modification  of — Sabine's  method 
— Pancoast's  subcutaneous  method — Saddle-back  and  angular  deformities  of 
the  nose — Paraffin  treatment — Konig's  method — Martin's  method — The  use 
of  gold,  silver,  rubber,  etc.,  in — Comments — Disfigurements  of  nose — Morbid 
growths — Author's  case— Harelip — Age  of  operation — Control  of  patient — 
Instruments  employed  in — Steps  of — Single  harelip — Mirault's  method — Mal- 
gaigne's  method — Hagedorn's  method — Simon's  method — Dieffenbach's 
method — Konig's  method — Giraldes's  method — Double  harelip — Compli- 
cated harelip — Management  of  projecting  intermaxillary  bones — Blandin's 
operation — Rose's  operation — operation  for  double  harelip — Hagedorn's 
method — Owen's  method — Cheiloplasty — Grant's  method — Blasius's  method 
— Celsus's  method — Estlander's  method — Langenbeck's  method — Bruns's 
method — Syme-Buchanan  method — Syme's  method — Buck's  method — Mal- 
gaigne's  method — Sedillot's  method — Dowd's  method — Deformities  of  the 
upper  lip — Buck's  method — Bruns's  method — Sedillot's  method — Dieffen- 
bach's method — Szymanowski's  method — Ledran-Mackenzie  method — Van- 
zette's  method — Stomatoplasty — Buck's  method — Serre's  method — Melo- 
plasty — ^Grussenbauer's  method — Trendelenburg's  method — Israel's  method 
— Kraske's  method — Lallemand's  method,  etc.^ — Operations  upon  palate — 
Instruments  employed  in — Staphylorrhaphy — Comments — Rose's  position 
in — Steps  of  operation  of  staphylorrhaphy — Results — Uranoplasty — Langen- 
beck's method — Steps  in — Dieffenbach-Fergusson  method — Lannelongue's 
method — Davies-Colley  method — Ferguson's  method — General  comments — 
After-treatment — Results — Mechanical  means  employed  in — Staphyloplasty 
— Schonborn's  operation — Lane's  method — Elongated  uvula        .         .         .     569 

CHAPTER  XIII. 

OPERATIONS   ON  MOUTH,    PHARYNX,    NOSE,    CESOPHAGUS,    AND   NECK. 

Salivary  fistula— Agnew's  method  of  cure — Dessault's  method — Van  Buren's 
method — Richelot's  method — Dequise's  method — Excision  of  tonsil — Re- 
moval with  knife  or  scissors — Abscess  of  tonsil — Operations  on  tongue — Lan- 
genbeck's method — Preliminary  laryngotomy — Excision  of  tongue — V- 
shaped  incision — Hypertrophy  of  tongue — Removal  of  entire  tongue — Re- 
moval of  half  of  tongue — Operation  through  mouth — ^Whitehead's  method — 


CONTENTS  OP   VOLUMK   I  XV 


PAGE 


Kocher's  method-Removal  of  tongue  with  division  of  jaw-Jaegcr  s  method 
-Balcer's  method-Rignoli's  method-Bill  roth's  method-choice  of  method 
-The  results-Tongue-tie-Ranula-Removal  of  tumor  of  tonsil  and  pillar 
of  fauces-Pharyngotomy^heever's  method-Czerny's  method-Mikulicz  s 
method-General  remarks-The  results-Operations  on  nos^Plugging  of 
posterior  nares-Removal  of  nasal  polypi-Removal  of  some  nasal  and  naso- 
nharvnc^eal  polypi-Nasal  route-Chassaignac's  method-Olher's  method- 
fawre^Wmetfod-Rouge'smethod-Langenbeck'smethod-Pa^^ 
--Ne'laton's     method-Chalot's    method-Annandale's     method-Maxillaiy 
route-Boeckel's   method-Guerin's  method-KoehoT's  method-Xheever  s 
method-General  comments-Choice  of  operation-The  resul  s-Deviation 
^f  septum  nasi-Operations  for-Operations  on  cesophagus-The  anato.mcal 
points-Foreign    bodies    in    cesophagus-The   remarks-Introduction    into 
Esophagus  of  Tnstruments-A  m  thod  of  introduction  of  stomach  tube-0  her 
method^  of  introduction-The  precautions-The  remarks-Ingenious  plans 
o  action  for  removal  of  special  obstructions-CEsophagotomy-Cervical  ceso- 
phagotomy-The  fallacies-The  remarks-The  after-treatment-The  results 
-Foreign  bodies  in  thoracic  cesophagus-Operations  on  cBsophagus-Gas- 
trotomy-The    operation-The    precautions-The    comments-S  ricture    of 
Sophagus-Treitment   of-By   dilatation-By   retrograde    dilatation-By 
Tvulsio^-By  direct  and  retrograde  divulsion-Internal  oesophagotomy- 
M   m^  by  sl-ing  friction-The  comments-Tubage-The  --l^s-(Esopha- 
gectomy-The  re.ults-(Esophagotomy-Operations  on  neck-Bronchotomy 
Anatomical  points-The  after-treatment-Laryngotomy-Operation  of- 
^^hertomy-Anatomical    points-Operation    below    isthmus-Operation 
!w    sthm'us-Operation  through  isthmus-Laryi^o-tracheotom,;-Rapid 
Lvn-^o-tracheotomy-Operation  of-Thyrotomy-Operat.on   of-The  pre- 
cTutiot-t^^^  ment-The  results  of  trac^eo toniy 

-Subhyoid  pharyngotomy-Operation  of-Intubation  of  larynx-Introduc- 
tion of  tube^Afterttreatment^The  results-Foreign  bodies  m  -r  passages 
-Methods  of  treatment-The  results  -  Laryngectomy -Complete  aryn- 
.ectomy-Kocher's  method-The  results-Treves's  method-Partial  laryn- 
fectomy-Total  laryngectomy -Keen's  plan  of  operation  -  Tamponing 
fhe  tmchea-TrendeTenburg's  tampon-Hahn-Michael's  tampon-Gers  er  s 
flLnn  Artificial  larynx-The  results-Operations  on  thyroid  body-Ana- 
tampon— Artihcial  larynx  ^.:^„t— Partial  excision— Kocher's  method 

tomical  points— Preparation  of  patient— Partial  e^"^^"  removal 

-Angular  incision-Transverse  incision-Kocher  s  -«  ^od^-The  mnov^^ 

of  intra-thoracic  goitre-Enucleation  --.^^-^V^^^?^' ^  "^.^^^^^^^^^^^^^^ 
tion-Socin's   method-Resection  of    goitre-Kocher's  method-Recurrent 
gXe^^Tltmlt  of  ligature  of  thyroid  arteries-By  ^^^ll-^^^-^;Z 
dsion  of  sympathetic-By  injection-Dangers  of  «Pf/^^^°"^-^\7Xk- 
iZngeal-From  cellulitis-From  cachexia-The  results-Wound   of  neck 
TrTatmLt  of-Abscess  and  phlegmon  of  -ck-R^tropha^^^^^^^^^^^  absces 
Anatomical  points-Chiene's  method  ^V'T      T  T      c;^ootts-Stves's 
Removal  of  diseased  cervical  lymphatic  ^'--^^^^^f'^f'''^^^^^ 
operation-The   precautions-The    ^«--^l--fartey  s    method     Mitel  ve^l^s 
niethod-The    results-Branchial     cysts-Extirpation    of    parotid    .land        ^^^ 
Anatomical  points— Contra-indications  of— The  results  .         .         •         • 


ILLUSTRATIONS 


Abdominal  vessels,  linear  giiides  to.     Figs.  180,  ISl. 

Abscess,  retropharvTigeal,  opening  of.     Fig.   S93. 

Acupressure.     Figs.  9.3,  94,  95. 

Adams's  clamp.     Fig.  844. 

Adams's  saw.     Fig.  452. 

Amputating  knives.     Fig.  487. 

Amputating  knife,  how  held.     Fig.  488. 

Amputating  knife,  how  carried  aroiind  limb.     Fig.  489. 

Amputating  knife,  another  method,  carr\-ing  arovmd  limb. 

Amputating  knife,  common  method,  carrying  aroimd  limb. 

Amputation,  circular  method.     Fig.  473. 

Amputation,  dissection  of  flap.     Fig.  474. 

Amputation,  how  to  dissect  flap.     Fig.  475. 

Amputation,  circular  di^■ision  of  muscle?.     Fig.  476. 

Amputation,  circular,  stump  of.     Fig.  477. 

Amputation,  modified  circular  flap.     Fig.   478. 

Amputation,  flaps  by  transfixion.     Fig.  480. 

Amputation,  part  removed  by  transfixion.     Fig.  481. 

Amputation,  skin  flaps,  equilateral.     Fig.  484. 

Amputation,  improper  periosteal  flap.     Fig.  485. 

Amputation,  instruments  employed  in.     Fig.  486  (half  tone) 

Amputation,  sawing  bone.     Fig.  495. 

Amputation,  catching  and  tj-ing  bleeding  points.     Fig.  502. 

Amputation  at  wrist,   Dubrueil's  method.     Figs.  532,  533. 

Amputation,  arm,  Langenbeck's  method.     Fig.  540. 

Amputation  of  arm,  flaps.     Figs.  541,  542. 

Anaesthesia,  infiltration.     Figs.  25,  26. 

Ansesthesia,  infiltration,  Matas.     Figs.  27,  28. 

Anaesthesia,  spinal.     Figs.  29,  30,  31,  32. 

Anderson-Makin's  lines.     Fig.  287. 

Aneurism,  extirpation  of.     Figs.  232,  234. 

Aneurism,  radical  cure.     Figs.  235,  247. 

Aneurismal  needle,  student's.     Fig.  177. 

Aneurismal  needle,  Mott's.     Fig.  178. 

Ankle  joint,  excision  of.     Fig.  425. 

Ankle  joint,  anatomy  of.     Fig.  426. 

Ankle  joint,  excision  of.     Fig.  428. 

Ankle  joint,  anatomy  of.     Fig.  429. 

Ankle  joint,  splint  for  excision.     Fig.  430. 

Antiseptic  dressings  in  position.     Fig.  159. 

Approach  to  vessels.     Fig.  170. 

Arteries  of  neck,  linear  guides  to.     Fig.  205. 

Arteriorrhaphy.     Figs.  248,  249. 

Artery,  torsion  of.     Fig.  97. 

Astragalus,  excision  of.     Fig.  425. 

Atomizer,  Richardson's.     Fig.  21. 


PAGE 

181 
726 


Original. 

Esmarch. 

Thomas  Bryant. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

Original. 

Original. 

Fig.  490.  S.  Smith. 

Fig.  491.  Esmarch. 

Esmarch. 

Esmarch. 

Esmarch. 

Esmarch. 

Esmarch. 

Gross. 

Gross. 

Gross. 

Esmarch. 

Xew. 

Original. 

Esmarch. 

MacCormac. 

Esmarch. 

Esmarch. 

Esmarch. 

W.  F.  Ford  d:  Co. 

Matas. 

Tufjier.     41,  42 

Mills.     249 

Moynahan.     203,  205 

Matas.     20: 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

Treves,  modified. 

Esmarch. 

Treves,  modified. 

Esmarch. 

Esmarch. 

Watson. 

Original. 

New. 

Murphy.     213,  214 

Esmarch.       76 

Treves,  modified.     410 

W.  F.  Ford  S:  Co.       36 

xvii 


661 
433 
461 
462 
462 
463 
463 
453 
454 
454 
455 
455 
456 
457 
457 
458 
459 
460 
465 
468 
479 
484 
485 
39 
40 


213 
129 
129 
410 
411 
412 
413 
414 
109 
126 
159 


xvni 


ILLUSTRATIONS. 


Axillary  artery,  ligature  of,  first  portion.     Fig.  218. 
Axillary,  brachial  arteries,  ligature  of.     Fig.  219. 

Barton's  operation.     Fig.  673. 

Baudens's  amputation.     Fig.  569. 

Bobbins  for  ligatures.     Fig.  122. 

Bone  repair.     Figs.  371,  372,  373. 

Boston  surgical  cushion.     Fig.  60. 

Bottles  for  ligatures.     Figs.  124,  126. 

Brachial  artery,  pressure  digital.     Fig.  86. 

Brachial  artery,  tourniquet  applied  to.     Fig.  89. 

Brain,  puncturing  of  ventricles.     Fig.  264. 

Brain,  topography  of.     Figs.  289,  290a. 

Brain  tumor,  instruments  in  operations  on.     Fig.  290  (half  tone). 

Brandis's  method  of  compression.     Fig.  651. 

Broad-bladed  saw.     Fig.  492. 

Buck's  needle  conductor.     Fig.  96. 

Buck's  method.     Figs.  726,  727. 

Buck's  incision.     Fig.  776. 

Bullet  forceps.     Fig.  299. 

Bunion  and  hallux  valgus.     Fig.  691. 

Butcher's  bone  saw.     Fig.  494. 


Mott,  modified. 
Kocher. 


PAGE 

179 
181 


Gross.  559 

Modification.  502 

W.  F.  Ford  &  Co.  86 

Gerster.     358,  359 

W.  F.  Ford  &  Co.  54 

W.  F.  Ford  &  Co.  86 

MacCormac.  72 

Esmarch.  73 

Keen.  228 

Dalton,  modified.  252 

Original.  252 

Esmarch.  542 

W.  F.  Ford  &  Co.  464 

W.  F.  Ford  &  Co.  76 

Buck.  583 

Buck.  610 

W.  F.  Ford  &  Co.  268 

Gross.  568 

W.  F.  Ford  &  Co.  464 


Garden's  amputation.     Fig.  626. 

Carotid,  vertebral  and  facial  arteries.     Fig.  217. 

Carotid,  common,  ligature  of.     Fig.  228. 

Carpus,  synovial  membranes  of.     Fig.  413. 

Carpus,  ligaments  of  dorsal  surface.     Fig.  414. 

Carpus,  ligaments  of  palmar  surface.     Fig.  415. 

Carpus,  transverse  section  of.     Fig.  416. 

Catgut  in  glass  tubes.     Fig.  125. 

Cautery,  actual,  blowpipe  and  irons.     Fig.  107. 

Cautery,  galvanic,  electrodes.     Fig.  109. 

Celsus's,  amputation  of  thigh.     Figs.  673,  639. 

Celsus's  method.     Figs.  768,  769. 

Chain  saw.     Fig.  376. 

Chain  saw  carrier.     Fig.  377. 

Cheeks  drawn  aside  by  elastic  traction.     Fig.  799. 

Cheiloplasty,  Estlander  method.     Fig.  770. 

Cheiloplasty,  Langenbeck  and  Briins.     Figs.  771,  772. 

Cheiloplasty,  Langenbeck,  Syme-Buchanan.     Figs.  773,  774. 

Chin,  cheek,  and  lip,  repair  of,  Vanzette's  method.     Fig.  786. 

Chopart's  amputation.     Figs.  575-579. 

Closure  of  vessel  en  masse.     Fig.  128. 

Clot  dural,  exposure.     Figs.  278,  279. 

Columna,  repair  of.     Fig.  728. 

Common  iliac,  ligaturing  of.     Fig.  182. 

Compress,  pyramidal.     Fig.  82. 

Compress,  oblong.     Fig.  83. 

Compress,  conical.     Fig.  84. 

Counter-opening,  locating  of,  author's  method.     Fig.  300. 

Counter-opening,  located,  author's  method.     Fig.  301. 

Cranial  bones,  section  of.     Fig.  280. 

Cranial  fissures  and  sutures,  relation  of  in  adult.     Fig.  282. 

Cranial  fissures  and  sutures,  relation  of  in  child.     Fig.  283. 

Craniotomy,  for  fracture  of  the  skull,  instruments  used  in.   Fig. 

Craniotomy,  circular.     Fig.  266. 

Craniotomy  (trephining).     Figs.  267,  268,  269,  270,  271,  272. 


Stimson.     528 

Kocher.     175 

Sedillot,  modified.     192 

Gray.     401 

Esjnarch.     401 

Esmarch 

Treves 

W.  F.  Ford  &  Co 

W.  F.  Ford  &  Co 

W.  F.  Ford  &  Co. 

Esmarch.     536 

New.     607 

W.  F.  Ford  &  Co.     364 

W.  F.  Ford  &  Co.     364 

Dennis. 

Tillm,anns 

Tillmanns 

Tillmanns. 

Terrier. 

Esmarch.     504,  506 

Esmarch.       96 

Lejars. 

Treves. 

Modified  from  Otis. 

Esmarch. 

Esmarch. 

Esmarch. 

Original.     268 

Original.     269 

Chipault.     243 

Morris.     282 

Morris.     283 

295  (halftone).  Original.     232 

Esmarch,  modified.     233 

Jacobson  and  Scudder, 

modified.     232,  236 


401 
402 

87 
79 
80 


622 
607 
608 
608 
615 


240 

583 

133 

71 

71 

71 


ILLUSTRATIONS.  ^^ 

PAGE 

Craniotomy,  sites  for.      Fig.  292.  Treves.  259 

Crile's  suit  for  shock.      Fig.  167.  Crile.  121 

Croft's  operation.     Fig.  714.  Treves.  57S 

Crural  nerve,  anterior.     Fig.  338.  Agnew.  338 

Cutting  skin  grafts.      Fig.  712.  Dennis.  576 

Cutting  skin  grafts.     Fig.  713.  Esmarch.  577 

Davy's  lever  applied.     Fig.  91.  Davy.  74 

De  Lignerolle's  amputation.     Figs.  581,  586.  E.imarch.     506,  508 

Denonvillier's  method.     Fig.  725.  Tillmanns.  582 

Diagram  of  arrangements.     Fig.  164.  Treves.  116 

Dieffenbach's  method.     Fig.  729.  Stimso?7,  modified.  584 

Dieffenbach's  flap.     Fig.  735.  Treves.  588 

Dieffenbach's  method?     Fig.  752.  Treves.  601 

Digits,   tendinous  slieaths  of.     Fig.  369.  Gerster.  354 

Dorsalis  pedis,  ligature  of.     Fig.  202.  Kocher.  155 

Douching  bottle.     Fig.  157.  W.  F.  Ford  &  Co.  109 

Douching  bottle,  extemporized.     Fig.  158.  W.  F.  Ford  &  Co.  109 

Doyan's  method.     Figs.  321,  324.  Doyan.  303 

Drainage  tube,  rubber,  thread  fastening.     Fig.  153.  Original.  105 

Drainage  tube,  rubber,  pin  fastening.     Fig.  154.  Original.  106 

Drainage  strips,  iodoform  gauze.     Fig.  155.  W.  F.  Ford  &  Co.  106 

Drainage,  catgut.     Fig.  156.  Wyeth.  106 

Drainage,  base  of  skull.     Fig.  332.  Parkin.  317 

Dupuytren's  contraction.     Figs.  366,  367.  Abbe.  351 

Elbow  joint,  excision,  Hiiter's  incision.     Fig.  406.  Esmarch.  396 

Elbow  joint,  ligaments  of.     Fig.  407.  Gray.  396 

Elbow  joint,  excision,  Langenbeck's  incision.     Fig.  408.                   MacCormac,  modified.  397 

Elbow  joint,  excision,  OUier's  incision.     Fig.  408.                               MacCormac,  modified.  397 

Elbow  joint,  excision,  Liston's  incision.     Fig.  409.  Esmarch.  397 

Elbow  joint,  excision,  exposing  internal  condyle.     Fig.  410.  Esmarch.  398 

Elbow  joint,  excision,  splint  applied.     Fig.  411.  Esmarch.  399 

Elbow  joint,  amputation  at,  elliptical  flap.     Fig.  535.  Treves.  481 

Elbow  joint,  amputation  at,  circular  method.     Figs.  536,  537.  Esmarch.  482 

Elbow  joint,  amputation  at,  by  transfixion.     Figs.  538,  539.  S.  Smith.  48S 

Ellis's  method.     Fig.  723.  Roberts.  582 

Epigastric  artery,  ligature  of.     Fig.  189.  Kocher.  141 

Esmarch's  tourniquet.     Fig.  647.  Esmarch.  540 

Esmarch's  tourniquet  applied.     Fig.  649.  Esmarch.  541 

Esmarch's  elastic  bandage.     Fig.  75.  Esmarch.  69 

Esmarch's  elastic  bandage  applied.     Fig.  76.  Esmarch.  69 

Ethyl  chloride,  spray.     Fig.  22.  W.  F.  Ford  &  Co.  37 

Excision  of  bones  of  the  face,  instruments  employed  in.     Fig.  378  (half  tone).  Original.  366 

Excisions  of  extremities,  instruments  employed  in.     Fig.  375  (half  tone).  Original.  363 

Extemporized  retractors.     Fig.  176.                                                     Modified  from  Es7narch.  129 

Fascia,  deep  cervical.     Fig  892.  Gray.  725 

Fascia  palmar.     Fig.  365.  Morris.  350 

Fasciatome.     Fig.  364.  W.  F.  Ford  &  Co.  349 

Fasciatome,  short.     Fig.  368.  W.  F.  Ford  cO  Co.  351 

Femoral  artery,  digital  pressure  on.     Fig.  85.  MacCormac.  71 

Femoral  artery,  tourniquet  applied  to.     Fig.  88.  Esmarch.  73 

Femoral  artery,  superficial,  ligature  of.     Fig.  190.  Kocher.  144 

Femoral  artery,  deep,  ligature  of.     Fig.  194.  Kocher,  modified.  148 

Femur,  lower  end  of,  transverse  section.     Fig.  461.  Treves,  modified.  443 

Fibula,  removing  end  of.     Fig.  427.  <S.  Smith.  412 

Finger  stalls,  rubber.     Fig.  163  (half  tone).  Original.  115 

Fingers,  amputation  of,  appearance  of  fiaps.     Figs.  513,  514.        Esmarch  and  Jacobson  473 


XX 


ILLUSTRATIONS. 


Fissure  of  Rolando,  locating,  Chiene's  method.     Fig.  285. 

Flap,  single  pedicle.      Figs.  715,  717. 

Flap,  single  pedicle,  author's  case.     Fig.  718. 

Flaps,  double  pedicle.      Fig.  716. 

Fluhrer's  probe.      Fig.  297. 

Forcep.'s,  serre-fine.     Fig.  102. 

Forceps,  tongue-holding,  Mathieu's.     Fig.  2. 

Forceps,  isolation,  anaesthesia.     Fig.  24. 

Forceps,  thumb.     Fig.  40. 

Forcejis,  claw-bite.     Fig.  42. 

Forceps,  cutting  between.     Fig.  41. 

Forcipressure,  patterns  of.     Fig.  106. 

Forearm,  stump  after  circular  amputation  of.     Fig.  534. 

Foulis's  fastening.     Figs.  78,  79. 

Framework  of  nose,  formation  of.     Fig.  733. 


Keen. 

Wyeth. 

Original. 

Tillmanns. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

Lobker. 

W.  F.  Ford  &  Co. 

Esmarch. 

t.  Esmarch. 

Tillmanns. 


Genu  valgum.     Fig.  460. 

Genu  varum.     Fig.  469. 

Giraldes's  method.     Fig.  754. 

Girdner's  electric  probe.     Fig.  298. 

Gland,  borated,  anatomy  of.     Fig.  897. 

Gland,  borated,  surgical  anatomy  of.     Fig.  898. 

Glands,  cervical  lymphatic,  instruments  for  removal  (half 

Glands,  cervical  lymphatic.  Hartley's  method.     Fig.  845. 

Glands,  cervical  lymphatic,  Mitchell's  method.     Fig.  896. 

Gloves,  canton  flannel.      Fig.  162  (half  tone). 

Gluteal  and  sciatic  arteries,  guides  to.     Fig.  184. 

Gluteal  artery,  ligature  of.     Fig.  185. 

Gouging,  instruments  employed  in.      Fig.  370  (half  tone). 

Grad,  method  of  ligature  removal.     Fig.  121. 

Granny  knot.     Fig.  115. 

Gritti's  amputation.     Fig.  568. 

Grooved  director.     Fig.  46. 

Gross's  needle  forceps.     Fig.  800. 

Gross's  artery  compressor.      Fig.  104. 


Poore. 

Poore. 

Tillm,anns. 

W.  F.  Ford  &  Co. 

Testut. 

Esmarch,  m.odified. 

tone).     Fig.  894.       Original. 

Stimson. 

Johns  Hopkins  Hospital  Rpt. 

Original. 

MacCormac. 

Kocher. 

Original. 

Grad. 

Heath. 

Stimson. 

W.  F.  Ford  &  Co. 

Gross. 

W.  F.  Ford  &  Co. 


Hagedorn's  method.      Fig.  750.  Tillmanns. 

Halux  valgus.     Fig.  471.  Tubby. 
Hamilton's  artery  forceps.     Fig.  100.                                                             W.  F.  Ford  &  Co. 

Hammer-toe.     Fig.  678.  Tubby. 

Hancock's  amputation,  bones  sawed  through.     Fig.  585.  Esmarch. 

Hand,  appearance  of.     Fig.  522.  Watson. 

Hand  and  forearm  protection.     Fig.  165    (half  tone).  Original. 

Hand  conservatism  illustrated.     Fig.  503.  Jacobson. 

Hand,  palm  of,  surface  markings.     Fig.  504.  Treves. 
Hand-lamp  for  illumination.     Fig.  110.                                                         W.  F.  Ford  &  Co. 

Harelip,  double.     Fig.  755.  S.  Smith. 

Harelip,  complicated.     Fig.  756.  Gross. 

Harelip,  double,  operation  for.     Fig.  758.  Tillmanns. 

Harelip,  double,  Hagedorn's  operation.     Fig.  759.  Tillmanns. 

Harelip,  pins  inserted.      Fig.  762.  Gross. 

Harelip,  instruments  employed  in.     Fig.  747  (half  tone).  Oriqinal. 

Hartley-Krause  method,  lines  of  incision.     Fig.  318.  Chalot. 

Hartley-Krause  method,  making  bone  flap.     Fig.  319.  Chalot. 

Hartley-Krause  method,  branches  fifth  nerve.     Fig.  320.  Chalot. 

Head,  antero-posterior  section  of.     Fig.  263.  Keen. 

Hip  joint,  amputation  of,  Wyeth's  method.     Figs.  650,  652.  Wyeth. 

Hip  joint,  amputation  of,  Menec's  method.     Figs.  660,  663.  Esmarch. 


ILLUSTRATIONS. 


XXI 


Hip  joint,  amputation  of,  Dieffenbach's  method.     Figs.  665,  667. 

Hip  joint,  amputation  of,  Furneaux  Jordon  method.     Fig.  668 

Hip  joint,  amputation  of,  Guthrie's  method.      Fig.  669. 

Hip  joint,  amputation  of,  Malgaigne.      Figs.  670,  672. 

Hip  joint,  Senn's  metliod.     Figs.  656,  659. 

Hip  joint,  Wliite's  incision  in  excision  of.      Fig.  446. 

Hip  joint,  nerve  and  rotary  muscles  of.      Fig.  447. 

Hip  joint,  sawing  off  liead  in  excision  of.     Fig.  448. 

Hip  joint,  Langenbeck's  incision  in  excision  of.     Fig.  449. 

Hip  joint,  Sayre's  incision  in  excision  of.     Fig.  449. 

Holding  Ivnife,  first  position.     Figs.  34,  35. 

Holding  knife,  second  position.     Figs.  36,  37. 

Holding  knife,  third  position.     Figs.  38,  39. 

Horsley's  fissure  meter.     Fig.  285. 

Hughson's  torsion  forceps.     Fig.  98. 

Humerus,  excision  of  head  of.     Fig.  336. 

Humerus,  epiph3'sis  of.     Fig.  391. 

Humerus,  excision  of  head,  incision  for.     Fig.  392. 

Humerus,  excision  of  head  of,  raising  tendon.     Fig.  393. 

Humerus  attachments,  tuberosities  of.     Fig.  394. 

Humerus,  excision  of  head  of.     Fig.  395. 


Iliac  artery,  external,  ligatvire  of. 
Iliac  arterj^,  common,  ligature  of. 
Incisions  in  maxillae.     Fig.  385. 
Indian  method.     Fig.  731. 
Inferior  maxilla.  Keen's  method. 
Inferior  maxilla,  Kiihn's  method. 
Inferior  maxilla,  Liicke's  method. 
Inferior  maxilla,  Horsley's  method 


Fig.  188. 
Fig.  183. 


Fig.  314. 

Fig.  314. 

Fig.  314. 
,     Fig.  314. 


12. 


Inferior  maxilla,  Linhart's  method.     Fig.  314. 

Inferior  maxilla,  Pancoast's  method.      Fig.  314. 

Inferior  maxilla,  removal  of  lines  of  incision.     Fig.  384. 

Inferior  maxilla,  severing  connections  of.     Fig.  386. 

Inferior  dental  nerve,  resection  of.     Fig.  313. 

Infusion,  apparatus  for.     Figs.  253,  254  (half  tone). 

Ingro\^TQ  toe  nail,  operations  for.     Fig.  688. 

Ingrown  toe  nail,  transverse  section  showing.     Fig.  689. 

Ingrown  toe  nail,  Anger's  operation.     Fig.  690. 

Inhaler,  cloth  and  paper.     Fig.  9. 

Inhaler,  AlUs's.     Figs.  10,  11. 

Inhaler,  Fowler's  modification  of  Allis's  collapsable.     Fig. 

Inhaler,  Bennett's,  ether.     Fig.  15. 

Inhaler,  Bennett's,  nitrous  oxide.     Fig.  19. 

Inhaler,  Bennett's,  "gas  and  ether."     Fig.  20. 

Inhaler,  Clover's.     Fig.  13. 

Inhaler,  Ormsbj''s.     Fig.  14. 

Inhaler,  Esmarch's  chloroform.     Fig.  16. 

Inhaler,  Junker.     Fig.  17. 

Inhaler,  .Junker's  nasal  and  pharjoigeal  tubes.     Fig.  18. 

Innominata,  ligature  of.     Figs.  207,  208,  209,  210. 

Innominata,  ligature  of,  Curtis.     Figs.  211,  212. 

Intermaxillary  bone,  Blandin's  operation.      Fig.  757. 

Interrupted  suture.     Fig.  139. 

Intracranial  neurectomy,  instruments  employed  in.     Fig.  317 

Intracranial  neurectomy,  Cushing  method.      Figs.  322,  323. 

Intracranial  neurectomy,  Spiller-Frazer  method.     Fig.  325. 

Iodoform  sprinkler.     Fig.  160. 

Italian  method.     Fig.  711. 


PARE 

37.                       Esmarch. 

553 

'<■                                Treves. 

555 

Treves. 

555 

S.  Smith. 

555 

Senn. 

.546 

Esmarch. 

426 

Esmarch. 

426 

Esmarch. 

422 

Esmarch. 

428 

Esmarch. 

428 

Bernard  &  Huette. 

46 

Bernard  &  Huette. 

46 

Bernard  &  Huette. 

46 

Mills. 

247 

W.  F.  Ford  &  Co. 

77 

Esmarch,  modified. 

384 

Treves. 

385 

Esmarch,  modified. 

385 

Esmarch. 

386 

Esmarch. 

386 

Esmarch. 

387 

Mott. 

139 

Kocher. 

134 

Treves. 

376 

Treves. 

586 

Keen. 

290 

Kocher,  modified. 

290 

Kocher,  modified. 

290 

Kocher,  modified. 

290 

Kocher,  modified. 

290 

Kocher,  modified. 

290 

Kocher,  modified. 

375 

Agnew. 

377 

Kocher,  modified. 

286 

Original.     219, 

,  220 

Dowd,  modified. 

567 

Stimson. 

567 

Doird. 

568 

Original. 

25 

W.  F.  Ford  &  Co. 

26 

W.  F.  Ford  &  Co. 

26 

W.  F.  Ford  &  Co. 

28 

W.  F.  Ford  *  Co. 

33 

W.  F.  Ford  &  Co. 

34 

W.  F.  Ford  &  Co. 

27 

W.  F.  Ford  &  Co. 

27 

Esmarch. 

30 

W.  F.  Ford  &  Co. 

31 

W.  F   Ford  &  Co. 

31 

New. 

162 

Curtis. 

165 

Dennis. 

604 

S.  Smith. 

101 

(half  tone).          Original. 

297 

Cushing.     304 

,  305 

Spiller  and  Frazer. 

30S 

W.  F.  Ford  &  Co. 

110 

Ancient. 

575 

xxn 


ILLUSTRATIONS, 


Janeway's  sphygmomanometer.     Fig.  168  (half  tone). 

Jaw  pry,  wooden.     Fig.  6. 

Jaw,  pushing  forward.     Fig.  8. 

Joint,  metatarso-phalangeal,  excision  of.     Fig.  428. 

Jumping,  pedicle  not  twisted.     Fig.  709. 

Jumping,  pedicle  much  twisted.     Fig.  710. 

Jumping,  repair  by.     Figs.  722,  724. 

Kangaroo  tendon  in  glass  tube.     Fig.  129. 

Keegan's  operation.     Fig.  737. 

Keen's  electrode.     Fig.  291. 

Kelly's  surgical  cushion,  large.     Fig.  58. 

Kelly's  surgical  cushion,  small.     Fig.  59. 

Keyes's  needle,  varicocele  treatment  of.     Fig.  251. 

Kingsley's  interdental  splint.     Fig.  826. 

Knee  joint,  anatomy  of.     Fig.  433. 

Knee  joint,  excision  of,  Mackenzie.     Fig.  434. 

Knee  joint,  excision  of,  sawing  femur.     Fig.  435. 

Knee  joint,  excision  of,  sawing  tibia.     Fig.  436. 

Knee  joint.  Bird's  incision  in  excision  of.     Fig.  437. 

Knee  joint,  Langenbeck's  incision  in  excision  of.     Fig.  439. 

Knee  joint,  anatomy  of.     Fig.  440. 

Knee  joint,  saw  lines  in  excision  of.     Fig.  442. 

Knee  joint,  Ollier's  incision  in  excision  of.     Fig.  441. 

Knee  joint,  epiphyseal  cartilages  of.     Fig.  443. 

Knee  joint,  splint  for  excision  of.     Fig.  445. 

Knee  joint,  cuneiform  excision  of.     Fig.  459. 

Knee  joint,  amputation  at.     Figs.  618-620. 

Knee  joint,  amputation  at,  circular  method.     Figs.  621-623. 

Knee  joint,  amputation  at,  in  anterior  third,  posterior  flap. 

Knee  flexion,  force  of.     Fig.  74. 

Konig's  method,  nose.      Fig.  740. 

Konig's  inethod,  lip.     Fig.  753. 

Krug's  inclined  plane,  portable.     Fig.  71. 


PAGE 

Janeway.  123 

Original.  14 

Esmarch.  13 

Treves,  modified.  412 

Lobker.  574 

Prince.  574 

Gross.  582 


W.  F.  Ford  &  Co. 

Treves. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

Kingsley. 

Morris 

Esmarch. 

Treves. 

Treves. 

Esmarch. 

Esmarch. 

Esmarch. 

S.  Smith. 

Esmarch. 

Stimson. 

Esmarch. 

Treves,  modified. 

S.  Smith. 

Esmarch. 

Figs.  624,  625.    Esmarch. 

Tillmanns. 

Tillmanns. 

Tillmajins. 

W.  F.  Ford  &  Co. 


Laminectomy,  instruments  employed  in.     Fig.  326  (half  tone). 

Laminectomy,  exposure  of  posterior  structures.     Fig.  327. 

Laminectomy,  spinal  cord  exposed.     Fig.  327. 

Laminectomy,  removal  of  bone  pressure.     Fig.  329. 

Laminectomy,  osteoplastic  flap.     Fig.  330. 

Langenbeck's  clamp.     Fig.  380. 

Langenbeck's  method.     Fig.  724. 

Langenbeck's  serre-fine.     Fig.  103. 

Langenbeck's  saw.     Fig.  451. 

Langenbeck's  flap.     Fig.  736. 

Larynx,  instruments  for  intubation.     Fig.  871  (half  tone). 

Larynx,  intubation  of,  introducing  tube.     Figs.  872,  896. 

Larynx,  Gussenbauer's  artificial.     Fig.  881. 

Laving  basin.     Fig.  72. 

Leg,  amputation  of,  lower  third,  Guyon  and  Duval's  methods.     Fig 

Leg,  amputation  of,  lower  third,  author's  method.     Figs.  609,  611 

Leg,  amputation  of,  lower  third.     Figs.  612,  613. 

Leg,  amputation  of,  Bier  and  Eiselberg.     Figs.  628,  629. 

Leg,  amputation  of.  Bier  method.     Fig.  631. 

Leg,  amputation  of,  middle  third,  long  external  flap.     Fig.  614. 

Leg,  amputation  of,  upper  third.     Figs.  615,  616. 

Leg,  amputation  of,  middle  third,  bilateral  flap.     Fig.  617. 

Levis's  blunt  dissector.     Fig.  48. 

Ligature  of  arteries,  instruments  for.     Fig.  175  (half  tone). 


Original. 

Chipault. 

Chipault. 

Chipault. 

Chipault. 

Esmarch. 

Lobker. 

W.  F.  Ford  &  Co. 

W.  F.  Ford  &  Co. 

Treves. 

Original . 

Lojars. 

Tillmanns. 

W.  F.  Ford  &  Co. 

608.  Treves. 

Original. 

Treves. 

Zuckerkemdl. 

Bier. 

Esmarch. 

Treves. 

S.  Smith. 

W.  F.  Ford  &  Co. 

Original. 


97 
589 
253 

54 

54 
217 
643 
416 
417 
418 
418 
419 
420 
420 
421 
421 
422 
423 
442 
524 
526 
527 

68 
591 
602 

59 

309 
313 
313 
314 
315 

70 
582 

78 
433 
588 
694 
695 
708 

60 
516 
517 
519 
531 
531 
521 
522 
523 

49 
128 


ILLUSTRATIONS. 


xxm 


Ligature,  tying  of.     Figs.  112,  118. 

Ligatures,  receptacle  for,  in  office,  etc.     Fig.  127. 

Ligaturing,  subcutaneous.     Figs.  257,  259. 

Ligaturing,  svibcutaneous.     Figs.  260,  263. 

Lingual  artery,  ligature  of.     Fig.  229. 

Lingual  artery,  ligature  of,  third  situation.     Fig.  230. 

Lip,  epithelioma  of.     Fig.  763. 

Lip,  lower.  Grant's  operation.     Fig.  763. 

Lip,  lower,  Owen's  operation.     Fig.  764. 

Lip,  lower,  Blasius's  method.     Figs.  765,  766. 

Lip,  lower,  Dowd's  method.     Fig.  779. 

Lip,  lower,  Briins's  method.     Figs.  7S0a,  7806. 

Lisfranc's  amputation.     Figs.  570,  574. 

Lister's  tourniquet.     Fig.  648. 

Liston's  spring-catch  forceps.     Fig.  99. 

Liston's  mouse-tooth  forceps.     Fig.  101. 

Looped  suture.     Fig.  801. 

Lower  lip.  Buck's  method.     Fig.  775. 

Lower  lip,  Sddillot's  method.     Fig.  778. 

Lucas-Championniere's  lines.     Fig.  288. 

Making  incision.     Fig.  169. 

Malgaigne's  method.     Fig.  749. 

Malgaigne's  method,  lower  lip.     Fig.  777. 

Malleoli,  oblique,  division  of.     Fig.  593. 

Mallet  finger.     Fig.  679. 

Martin's  bandage,  elastic.     Fig.  81. 

Martin's  nasal  support.     Fig.  741. 

Mastoid  antrum,  instruments  in  opening  of.     Fig.  293  (half  tone). 

Mastoid  antrum  exposed.     Figs.  294,  295,  296. 

Meloplasty.     Fig.  789. 

Meloplasty,  Gussenbauer's  method.     Fig.  790. 

Meloplast}'-,  Israel's  method.     Fig.  791. 

Meloplasty,  Kraske's  method.     Fig.  792. 

Meloplasty,  Lallemand's  method.     Fig.  793. 

Meningeal  artery,  middle.     Fig.  273. 

Meningeal  artery,  middle,  anterior  branch.     Fig.  274. 

Meningeal  artery,  middle,  anterior  branch,  in  groove.     Fig.  275. 

Metacarpal  bones,  fourth  and  fifth,  amputation  through.     Fig.  520. 

Metacarpal  bones,  amputation  through.     Fig.  521. 

Metacarpal  bones,  last  four,  amputation  of.     Figs.  523,  526. 

Metatarsal  bones,  amputation  through.     Figs.  566,  568. 

Mikulicz's  amputation.     Fig.  569. 

Milne's  serre-fine.     Fig.  103. 

Mirault's  method.     Fig.  748. 

Mouth  gag,  Denhard's.     Fig.  4. 

Myotome.     Fig.  363. 

Nasal  disfigurement,  operations  on.     Figs.  745,  746  (half  tone). 

Nasal  septum,  deviating  instruments  for.     Fig.  845  (half  tone). 

Needle-holder,  Hartley-Markoe.     Fig.  133. 

Needle-holder,  Sand's.     Fig.  134. 

Needle-holder,  Luer's.     Fig.  135. 

Needle-holder,  Halsted-Leur.     Fig.  136. 

Needle  wounds.     Fig.  132. 

Needles,  assorted  sizes  and  curves.     Fig.  131. 

Nerve  grafting,  Chalot.     Fig.  306. 

Nerve,  repair,  by  catgut.     Fig.  305. 

Nerve,  ulnar,  at  elbow.     Fig.  405. 

Nerves,  circumflex  and  musculo-spiral.     Fig.  404. 


Heath. 

82 

W.  F.  Ford  &  Co. 

91 

S.  Smith. 

225 

S.  Smith. 

225 

Kocher,  modified. 

199 

Heath,  modified. 

199 

Tillmanns. 

607 

Grant. 

606 

Owen. 

606 

Blasius. 

606 

Dowd. 

611 

Briins. 

612 

Esmarch. 

503 

Esmarch. 

541 

W.  F.  Ford  &  Co. 

77 

W.  F.  Ford  &  Co. 

77 

Gross. 

623 

Buck. 

609 

Tillmanns. 

611 

Roberts. 

250 

Bernard  &  Htiette.  126 

Tillmanns.  600 

Tillmanns.  611 

Origiiial.  511 

Morris.  563 

W.  F.  Ford  &  Co.  70 

Terrier.  593 

Original.  262 

A'ew.     263,  264 

Tillm,anns.  616 

Tillmanns.  617 

Tillmanns.  617 

Tillmanns.  618 

Terrier.  618 

Kronlein.  237 

Gray,  modified.  237 

Gray,  modified.  238 

Watson.  474 

Esmarch.  474 

Esmarch.  476 

Esmarch,    Treves.  501 

Original.  502 

W.  F.  Ford  &  Co.  78 

Tillmanns.  600 

W.  F.  Ford  &  Co.  13 

IT.  F.  Ford  &  Co.  347 


Original. 

Original. 
W.  F.  Ford  &  Co. 
W.  F.  Ford  &  Co. 
W.  F.  Ford  <fe  Co. 
W.  F.  Ford  &  Co. 

Tieman. 

W.  F.  Ford  &  Co. 

Tillmanns. 

Esmarch. 

Esmarch. 
Gray. 


597 
662 
100 
100 
100 
100 
99 
99 
275 
275 
395 
394 


XXIV 


ILLUSTRATIONS. 


Nerves,  musculo-spiral,  musculo-cutaneous,  circumflex.     Fig.  334. 
Nerves,  median  and  interosseous.     Fig.  335. 

Nerves,  great  sciatic,  small  sciatic,  external  popliteal.     Fig.  336. 
Nerves,  great  sciatic,  external  popliteal,  short  saphenous,  incisions 

Nerves,  primary  suture  of.     Fig.  302. 

Nerves,  Gleiss's  method,  secondary  suture.     Fig.  303. 

Nerves,  secondary,  suturing  of.     Fig.  304. 

Neuroplasty,  Duncan's  method.     Fig.  305. 

Neuroplasty.     Fig.  304. 

Nicaise's  compression  band.     Fig.  77. 

Nose,  inferior  view  of.      Fig.  738. 

Obturator  artery,  ligature  of.     Fig.  189. 

Occipital  artery,  ligature  of.     Fig.  231 

CEsophagotomy,  instruments  in.     Fig.  848  (half  tone). 

CEsophagotomy,  primary  incision.     Fig.  849. 

CEsophagotomy,  final  incision.     Fig.  850. 

CEsophagotomy,  string  friction,  Obbe.     Fig.  853. 

CEsophagotomy,  string  friction,  Obbe.     Fig.  854. 

CEsophagotomy,  string  friction,  author's.     Fig.  855. 

CEsophagotomy,  string  friction,  author's.     Fig.  856. 

CEsophagus,  instruments,  removal  foreign  bodies.     Fig.  486  (half  t 

(Esophagus,  introducing  tube  into.     Fig.  847. 

CEsophagus,  tubage  of.     Fig.  857. 

CEsophagus,  stricture  of,  instruments.     Fig.  852  (half  tone). 

CEsophagus,  diverticulum,  operation  on.     Figs.  858,  859,  860. 

Ollier's  method.     Fig.  739. 

Opening  sheath.     Fig.  171. 

Opening  vein.     Fig.  252. 

Operating  table,  extemporized.     Fig.  57  (half  tone). 

Operating  table,  Cleveland's.     Fig.  61. 

Operating  table,  Cleveland's,  Trendelenburg  position.     Fig.  62. 

Operating  table,  Fowler's,  first  position.     Fig.  63. 

Operating  table,  Fowler's,  second  position.     Fig.  64. 

Operating  table,  Fowler's,  third  position.     Fig.  65. 

Operating  table,  Markoe's.     Fig.  66. 

Operating  table,  Prior's  portable.     Fig.  67. 

Operating  table,  folded.     Fig.  68. 

Operating  table,  Edeboh's  portable.     Fig.  69. 

Operating  table,  folded.      Fig.  69. 

Oral  screw,  hard  rubber.     Fig.  5. 

Oral  pry,  wooden.      Fig.  6 

Os  calcis,  excision  of.     Figs.  424,  425. 

Os  calcis,  lines  of  section  through.     Fig.  596. 

Osteotomy,  instruments  employed  in.     Fig   450  (half  tone). 

Osteotomy,  holding  osteotome.      Fig.  455. 

Osteotomy,  sawing  neck  of  femur.     Fig.  456. 

Osteotomy,  Volkman's  section.     Fig.  458. 

Osteotomy,  Sayre's  section.      Fig.  457 

Osteotomy,  supracondyloid.     Fig.  463. 

Osteotomy,  supracondyloid.     Fig.  466. 

Osteotomy,  supracondyloid,  Ogsten's  method      Fig.  467 

Osteotomy,  supracondyloid.  Chain's  method.     Fig.  468. 

Osteotomy,  linear.     Fig.  470. 

Osteotomy,  cuneiform.      Fig.  470. 

Pad,  antiseptic  gauze.     Fig.  73    (half  tone). 
Pad  and  elastic-band  compression.     Fig.  585. 


PAGE 

Kocher,  modified. 

322 

Kocher,  modif.ed. 

323 

Kocher,  modified. 

325 

for  exposure  of. 

Fig.  337.     Kocher. 

326 

Esmarch. 

273 

Sajous. 

274 

Sajous. 

275 

Sajous. 

275 

Esmarch. 

275 

Esmarch. 

69 

Tillma7ins. 

590 

Kocher. 

141 

Kocher,  modified. 

201 

Original. 

667 

Esmarch. 

668 

Esmarch. 

669 

Obbe. 

675 

Obbe. 

675 

Original. 

676 

Original. 

676 

one).              Original. 

664 

Esmarch. 

665 

Dennis. 

678 

Original. 

673 

Richardson. 

679 

Stimson. 

591 

Esmarch. 

126 

Esmarch. 

218 

Dowd. 

53 

W.  F.  Ford  &  Co. 

55 

W.  F.  Ford  &  Co. 

55 

W.  F.  Ford  &  Co. 

56 

W.  F.  Ford  &  Co. 

56 

W.  F.  Ford  &  Co. 

57 

W.  F.  Ford  &  Co. 

57 

W.  F.  Ford  &  Co. 

58 

W.  F.  Ford  &  Co. 

58 

W.  F.  Ford  &  Co. 

59 

W.  F.  Ford  &  Co. 

59 

W.  F.  Ford  &  Co. 

14 

Original. 

14 

S.  Smith. 

409 

S.  Smith. 

512 

Original. 

432 

Tubby 

436 

Gross. 

437 

Gross. 

438 

Sayre. 

438 

Macewen. 

444 

Macewen. 

444 

Macewen. 

444 

Treves. 

444 

Treves. 

445 

Treves. 

445 

Original. 

63 

Esmarch. 

482 

ILLUSTRATIONS. 


XXV 


Palate,  instruments  employed  in  operations  on.     Fig.  794  (half  tone). 

Palate,  deformities  of.     Fig.  795. 

Palate,  muscles  of.     Fig.  797. 

Palmar  arteries.      Fig.  227. 

Pancoast's  tourniquet.     Fig.  646. 

Paper,  protective.     Fig.  692. 

Paquelin's  thermo-cautery.     Fig.  lOS. 

Passing  needle.     Fig.  172. 

Passing  a  probe.     Fig.  173. 

Passing  curved  needle.     Fig.  174. 

Peroneal  arterj',  ligature  of.     Fig.  204. 

Pctit's  tourniquet.     Fig.  87. 

Phalanges,  attachments  of,  tendons  of.     Fig.  505. 

Phalanx,  flexed.     Fig.  506. 

Phalanx,  amputation  of.     Figs.  507,  508. 

Phalanx,  amputation  of,  transfixion.     Figs.  509,  510. 

Pharyngotomy,  Cheever's,  Mikulicz's,  and  author's  incisions.     Fig 

Pharyngotomj',  low,  tumors  from,  author's  case.     Fig.  829. 

Pharyngotomj^,  subhyoid,  anatomy  of.     Fig.  870. 

Phillip's  head  Lamp  for  illumination.     Fig.  111. 

Phleborrhaphy.     Fig.  250. 

Pirogoff's  amputation.     Figs.  596,  600. 

Pirogoff's  amputation,  Le  Fort's  modification.     Figs.  601,  602. 

Pirogoff's  aniputation,  Briins's  modification.     Fig.  603. 

Pirogoff's  amputation,  Esmarch's  modification.      Figs.  604,  607. 

Plaster-of-Paris  jacket,  applied.     Figs.  674,  677. 

Plastic  surgery,  instruments  emplo3^ed  in.     Fig.  693  (half  tone). 

Plastic  surgery,  Dieffenbach's  method.     Figs.  698,  699. 

Plastic  surgerj^,  Burow's  method.     Figs.  701,  702. 

Plastic  surgery,  .Jaesche-Dieffenbach's  method.     Fig.  703. 

Plastic  surger}',  Littenneur's  method.     Fig.  704. 

Plastic  surgery,  Briins's  method.     Figs.  705,  706. 

Plastic  surgery,  Weber's  method.     Fig.  708. 

Plugging  posterior  nares.     Fig.  830. 

Polypus,  nasal,  looping  of.     Fig.  832. 

Polypus,  cannula  in  place.     Fig.  833. 

Polypus,  loop  applied.      Fig.  834. 

Polypus,  nasal,  Chossaignac's  method.     Figs.  835,  836. 

Polypus,  nasal.  Oilier  and  Lawrence's  method.     Fig.  837. 

Polypus,  nasal.  Rouge's  method.     Fig.  838. 

Polypus,  nasal,  Langenbeck  and  Boeckel's  method.     Fig.  839. 

Polypus,  nasal,  Langenbeck's  method  continued.     Fig.  840. 

Polj'pus,  nasal,  Nalaton's  and  Chalot's  methods.     Fig.  841. 

Poh'pus,  nasal,  Allier's,  Guerin,  Langenbeck,  incisions.     Fig.  842. 

Polypus,  naso-pharyngeal,  Kocher's  method.      Fig.  843. 

Popliteal  arterj-,  ligature  of.     Fig.  195. 

Popliteal  artery,  ligature  of  lower  third.     Fig.  197. 

Powell's  electric  saw.     Fig.  281. 

Prepared  for  operation.     Fig.  166  (half  tone). 

Pudic  artery,  ligaturing  of.     Fig.  186. 

Pudic  arterj-,  relations  of.     Fig.  187. 


Radial  and  ulnar  arteries,  ligature  of. 
Radial  artery,  ligature  of.     I'ig.  226. 
Ranula.     Fig.  827. 
Receptacle,  kidney  shape.     Fig.  52. 
Receptacle,  gLiss.     Fig.  54. 
Receptacle,  gutta-percha.     Fig.  53. 
Receptacle,  author's  rubber.     Fig.  55. 


Fig.  222. 


PAGE 

e). 

Original. 

619 

S.  Smith. 

620 

Esmarch. 

621 

Gray,  modified. 

190 

Esmarch. 

540 

Prince. 

570 

W. 

.  F 

.  Ford  &  Co. 

80 
127 

Esmarch. 

127 

Esmarch. 

127 

Kocher. 

1.57 

w. 

F 

.  Ford  &  Co. 

72 

Original. 

470 

Esmarch. 

470 

Esmarch. 

470 

Esmarch. 

471 

528. 

New. 

645 

Original. 

649 

Esmarch. 

693 

W. 

F. 

.  Ford  &  Co. 

81 

New. 

214 

Esmarch. 

512 

Esmarch. 

514 

Esmarch. 

514 

Esmarch. 

514 

Sayre. 

560 

Original. 

570 

Dennis. 

572 

Lobker. 

572 

Tillmanns. 

573 

Dennis. 

573 

Dennis. 

573 

Treves. 

574 

Esmarch,  modified. 

651 

Esmarch. 

653 

Packard. 

653 

Esmarch. 

653 

Esmarch. 

654 

Esmarch. 

654 

Esmarch. 

655 

Esr. 

nar 

ch,  modified. 

655 

Esmarch. 

655 

Treves. 

656 

New. 

658 

Tillmajins. 

659 

Koch 

ler,  modified. 

148 

Kocher. 

150 

W. 

F. 

Ford  d-  Co. 

243 

Original. 

117 

S.  Smith. 

138 

Morris. 

138 

Kocher. 

184 

Kocher,  modified. 

188 

S.  Smith. 

644 

W. 

F. 

Ford  d-  Co. 

51 

W. 

F. 

Ford  tt  Co. 

51 

W. 

F. 

Ford  cfr  Co. 

51 

W. 

F. 

Ford  &  Co. 

51 

XXVI 


ILLUSTRATIONS. 


Receptacle,  author's  rotary.     Fig.  56. 

Reef  knot.     Fig.  114. 

Reid's  lines.     Fig.  268. 

Relations  of  abdominal  vessels.     Fig.  179. 

Restraint,  method  of.     Fig.  1  (half  tone). 

Retractor  for  two  bones.     Fig.  496. 

Retractor,  three-tailed  applied.     Fig.  497. 

Retractor,  for  one  bone.     Fig.  498. 

Retractor,  two-tailed  applied.     Fig.  499. 

Retractor,  metal.     Figs.  500,  501. 

Retractors,  hooked.     Fig.  50. 

Ring,  isolation  ansesthesia.     Fig.  23. 

Rose  method,  trephining  base  of  skull.     Fig.  316. 

Rose's  position.     Fig.  796. 

Roux's  method.     Figs.  594,  595. 

Sabenejeff's  amputation.     Fig.  632. 

Salivary  fistula,  Desault's  method.     Fig.  814. 

Salivary  fistula,  Richelet's  method.     Fig.  815. 

Salivary  fistula,  Dequise's  method.     Fig.  816. 

Saw,  common  bone.     Fig.  493. 

Sayre's  jury-mast.     Figs.  674,  675. 

Scalpels  and  bistouries.     Fig.  33. 

Scapula,  entire  excision  of.     Fig.  387. 

Scapula,  body,  excision  of.     Fig.  388. 

Scapula,  excison  of,  subperiosteal.     Fig.  389. 

Scapula,  excision  of  angle.     Fig.  389. 

Sciatic  artery,  ligature  of.     Fig.  185. 

Scissors,  varieties  of.     Figs.  44,  47. 

Scissors,  manner  of  holding.     Fig.  48. 

Second  finger,  amputating,  oval  flap.     Figs.  511,  512. 

Sequestrotomy,  instruments  employed  in.     Fig.  374  (half  tone). 

Shoulder,  amputation  of,  racquet  flap.     Fig.  478. 

Shoulder  joint,  amputation  of.     Wyeth's  method.     Figs.  543,  544. 

Shoulder  joint,  amputation  at,  flap  method.     Fig.  545. 

Shoulder  joint,  amputation  at,  circular  method.     Fig.  548. 

Shoulder  joint,  oval -flap  method.     Figs.  550,  551. 

Shoulder  joint,  racquet-flap  method.     Fig.  552. 

Shoulder  joint,  amputation  at.     Figs.  553,  554. 

Shoulder  joint,  resection  of,  Senn's  method.     Figs.  396,  399. 

Shoulder  joint,  resection  of,  Kocher  method.     Figs.  400,  402, 

Shoulder,  dislocation,  McBurney's  hook.     Fig.  403. 

Shrady's  saw.     Figs.  453,  455. 

Silver  wire  in  special  tube.     Fig.  130. 

Simon's  method.     Fig.  751. 

Skey's  amputation.     Fig.  569. 

Sliding  in  a  direct  line.     Figs.  694,  697. 

Spinal  drainage.     Fig.  331. 

Spinal  nerves,  roots  of.     Fig.  333. 

Spinal  accessory  nerve,  the  linear  guides.     Fig.  214. 

Sponge-holder.     Fig.  7. 

Spools  for  silk.     Fig.  123. 

Staffordshire  knot.     Fig.  119. 

Stay-knot,  floss-silk.     Fig.  120. 

Sterilizer,  portable.     Fig.  161. 

Stokes's  amputation.     Fig.  627. 

Stomatoplasty,  Buck's  method.     Fig.  787. 

Stomatoplasty,  Serre's  method.     Fig.  788. 

Subclavian  right  and  innominate  arteries.     Fig.  206. 


PAGB 

W.F. 

Ford  &  Co. 

52 

Heath. 

82 

Starr. 

248 

Morris. 

130 

Original. 

12 

Esmarch. 

465 

Esmarch. 

466 

Esmarch. 

466 

Esmarch. 

466 

Griswold. 

467 

W.F. 

Ford  &  Co. 

50 

W.F. 

Ford  &  Co. 

37 

Chalot. 

255 

Rose. 

296 

Esmarch. 

512 

Tillmanns. 

532 

Ferrer. 

632 

Ferrer. 

632 

Ferrer. 

633 

fV.F. 

Ford  &  Co. 

464 

Sayre. 

560 

W.F. 

Ford  &  Co. 

45 

Modified. 

381 

Chalot. 

382 

Modified. 

383 

Esmarch,  modified. 

383 

Kocher. 

137 

W.F. 

Ford  &  Co. 

48 

Lobker. 

49 

Esmarch. 

472 

Original. 

360 

Esmarch. 

456 

4. 

Wyeth. 

487 

Esmarch. 

489 

Esmarch. 

490 

S.  Smith. 

492 

Treves. 

492 

Treves. 

493 

Senn. 

388 

Kocher. 

389 

W.F. 

Ford  &  Co. 

392 

W.  F. 

Ford  &  Co. 

433 

W.  F. 

Ford  &  Co. 

98 

Dennis. 

601 

New. 

502 

Lobker  and  Prince. 

571 

Chipault. 

316 

New. 

321 

Kocher,  modified. 

171 

Wyeth. 

14 

W.  F. 

Ford  &  Co. 

86 

Foster's 

1  Dictionary. 

84 

New. 

84 

W.F. 

Ford  &  Co. 

113 

Stimson. 

530 

Buck. 

615 

Treves. 

616 

MacCormac,  modified. 

159 

ILLUSTRATIONS. 


xxvn 


Subclavian  artery,  left.     Fig.  213. 

Subclavian  artery,  right,  anatomy  of.     Fig.  206. 

Subclavian  and  carotid  arteries.     Fig.  216 

Superior  maxilla,  divisions  of.     Fig.  379. 

Superior  maxilla,  incisions  in  removal  of.     Fig.  380. 

Superior  maxilla,  division  of.     Fig.  381. 

Superior  maxilla,  lines  of  incision  in  removal  of.     Fig.  382. 

Superior  maxilUe,  lines  of  incision  in  removal  of.     Fig.  383. 

Superior  and  inferior  maxilla,  lines  of  incision  in  removal  of.     ] 

Supernumerary  digits.      Fig.  680. 

Supraorbital  and  infraorbital  nerves,  divisions  of.     Fig.  308. 

Surgeon's  knot.     Fig.  113. 

Suture,  interrupted,  removal  of.     Fig.  141. 

Suture,  continuous.      Fig.  142. 

Suture,  continuous,  tying  of.     Fig.  143. 

Suture,  quill.     Fig.  144. 

Suture,  hare  lip.     Fig.  145. 

Suture,  twisted.     Fig.  146. 

Suture,  button.     Fig.  148. 

Suture,  relaxation  and  coaptation.     Figs.  149,  150. 

Sutures,  three-cornered  wounds.     Figs.  151,  152. 

Sutures,  deep  and  superficial,  alternating.     Fig.  140. 

Syme's  amputation.     Figs.  587,  592. 

S5Tiie's  operation  on  nose.     Figs.  720,  721.     , 

Szymanowski's  saw.     Fig.  437. 

Tarsus,  bones  of.     Fig.  569. 

Tarsus,  bone  and  membranes  of.     Fig.  423. 

Teale's  method,  amputation.     Figs.  482,  483. 

Tenaculum.     Fig.  105. 

Tendo  Achillis,  division  of.     Fig.  34. 

Tendo  Achillis,  rectification  after  division  of.     Fig.  342. 

Tendo  Achillis,  lengthening  of,  Poncet's  method.     Fig.  353. 

Tendo  Achillis,  lengthening  of.     Fig.  356. 

Tendo  Achillis,  shortening  of,  Z  method.     Fig.  359. 

Tendon  lengthening,  single-flap  method.     Fig.  350. 

Tendon  lengthening,  double-flap  method.     Fig.  351. 

Tendon  lengthening,  Anderson's  double-flap  method.     Fig.  352. 

Tendon  lengthening,  incision  method.     Figs.  354,  355. 

Tendon  transplantation,  first  series.      Fig.  360. 

Tendon  transplantation,  second  series.     Fig.  361. 

Tendon  anastomosis.     Fig.  362. 

Tenorrhaphy.     Fig.  343. 

Tenorrhaphy,  Witzel's  method.     Fig.  345. 

Tenorrhaphy,  quilt  suture.     Fig.  344. 

Tenorrhaphy,  Wolfler's  quilt  suture.     Fig.  346. 

Tenorrhaphy,  H liter's  peritendinous  suture.     Fig.  346. 

Tenorrhaphy,  Billroth's  bundle  suture.     Fig.  347. 

Tenorrhaphy,  oblique  coaptation  of  ends.     Fig.  348. 

Tenorrhaphy,  Hiiter's  method.      Fig.  349. 

Tenorrhaphy,  Gliick's  method,  catgut  repair.     Fig.  349. 

Tenotome,  pocket  case.     Fig.  340. 

Tenotomes.     Fig.  339. 

Tension  while  sewing.     Fig.  137. 

Tension  of  sutures.     Fig.  138. 

Tliiersch's  rhinoplasty.     Fig.  732. 

Thigh,  amputation  of  lower  third.     Fig.  633. 

Thigh,  amputation  of,  circular  division,  conical-shaped  cavity. 

Thigh,  amputated.     Fig.  635. 


PAGE 

MacCortnac,  modified. 

169 

Heath. 

159 

Kochcr. 

173 

TUlmannn. 

367 

Modified. 

368 

Afjnew. 

369 

Modified. 

370 

Modified. 

372 

rig.  384.           Modified. 

375 

Tubby. 

563 

Kocher,  modified. 

276 

Heath. 

82 

Esmarch. 

102 

Esmarch. 

102 

Original. 

102 

Thomas  Bryant. 

102 

Esynarch. 

102 

Esm.arch. 

103 

S.  Smith. 

104 

S.  Smith. 

104 

Wyeth. 

105 

Lobker. 

102 

Esmarch. 

509 

Synie. 

581 

W.  F.  Ford  &  Co. 

419 

Modified. 

502 

Gray. 

409 

Gross. 

458 

W.  F.  Ford  &  Co. 

78 

Sayre. 

334 

Sayre. 

334 

Chalot. 

341 

Chalot. 

342 

Chalot. 

343 

Chalot. 

341 

Chalot. 

341 

Anderson. 

341 

Chalot. 

341 

Vulpius. 

344 

Vulpius. 

344 

Chalot. 

345 

Sajous. 

339 

Sajoiis. 

339 

Sajous. 

339 

Esmarch. 

339 

Esmarch. 

339 

New. 

340 

Sajovs. 

340 

Esmarch. 

340 

Esmarch. 

340 

W.  F.  Ford  &  Co. 

330 

W.  F.  Ford  &  Co. 

329 

Treves. 

100 

S.  Smith. 

100 

Tillmanns. 

587 

Treves,  modified. 

533 

Fig.  634.                Gross. 

534 

Gross. 

534 

XXVlll 


ILLUSTRATIONS. 


Thigh,  amputations  of.     Fig.  636. 

Thigh,  amputation  of,  periosteal  flap.     Fig.  638. 

Thigh,  amputation  of,  Farabeuf's  method.     Fig.  640. 

Thigh,  amputation  of,  periosteum  over  bone.     Figs.  641,  643. 

Thigh,  amputation  of,  approximation  soft  parts.     Figs.  642,  644. 

Thigh,  amputation  of,  dressed.     Fig.  645. 

Thumb,  amputation  of,  oval  method.     Figs.  515,  517. 

Thumb,  amputation  of,  lateral-flap  method.     Figs.  518,  519. 

Thyroid,  excision  of,  Kocher's  method.     Fig.  882. 

Thyroid,  excision  of,  stages  of  operation.     Figs.  883,  886. 

Thyroid,  excision  of,  angular  incision.     Fig.  887. 

Thyroid,  excision  of,  dislocation  of  tumor.     Fig.  888. 

Thyroid,  excision  of,  left-sided  tumor.     Fig.  889. 

Thyroid,  excision  of,  Kocher's  grooved  director.     Fig.  890. 

Thyroid,  excision  of,  enucleation-resection.     Fig.  891. 

Tibial  artery,  anterior,  ligature  of.     Fig.  198. 

Tibial  artery,  posterior  ligature  of.     Fig.  203. 

Toe,  great,  single-flap  method.     Fig.  559. 

Toe,  great,  oval-flap  method.     Fig.  560. 

Toe,  great,  amputation  of.     Figs.  561,  562. 

Toe,  great,  amputation  through.     Fig.  555. 

Toes,  amputation  of.     Fig.  556. 

Toes,  amputation  of  all.     Figs.  563,  564. 

Toes,  great  and  little,  lateral-flap  method.     Figs.  557,  558. 

Tongue,  drawing  forward  of.     Fig.  3. 

Tongue,  operations  on,  instruments  (half  tone).     Fig.  817. 

Tongue,  V-shaped  incision.     Fig.  813. 

Tongue,  flaps  united.     Fig.  819. 

Tongue,  hypertrophy  of.     Fig.  820. 

Tongue,  Jaeger's  and  Rocher's  incisions.     Fig.  821. 

Tongue,  Sedillot's  incision.     Fig.  822. 

Tongue,  Roux,  Syme,  Rignoli,  and  Billroth's  incisions.     Fig.  822. 

Tourniquet,  improvised.     Fig.  90. 

Trachea,  diameters  of  tubes.     Fig.  861. 

Trachea,  topography  of.     Fig.  862. 

Trachea,  anatomy,  trachea  and  larynx.     Fig.  863. 

Trachea,  operations  on,  instruments  for.     Fig.  864  (half  tone). 

Trachea,  Langenbeck's  hook.     Fig.  865. 

Trachea,  laryngotomy  and  tracheotomy  incisions.     Fig.  866. 

Trachea,  laryngeal,  tracheal  incisions,  deep.     Fig.  867. 

Trachea,  opening  of.     Fig.  868. 

Trachea,  tube  in  position.     Fig.  869. 

Trachea,  tamponing,  Trendelenburg.     Figs.  877,  878. 

Trachea,  tamponing,  Hahn  and  Michael.     Fig.  879. 

Trachea,  tamponing,  Gerster's  tampon.     Fig.  880. 

Traction  loops.      Fig.  51. 

Transfusion,  introduction  of  tube.     Fig.  255. 

Transfusion  apparatus,  Collins's.      Fig.  256. 

Transverse  incision,  closure  by.     Figs.  695,  696. 

Transverse  section,  right  knee.     Fig.  196. 

Transverse  section,  right  leg,  upper  third.     Fig.  199. 

Transverse  section,  right  thigh,  upper  third.     Fig.  191. 

Transverse  section,  right  thigh,  middle  third.     Fig.  192. 

Transverse  section,  right  thigh,  lower  third.      Fig.  193. 

Transverse  section,  right  leg,  middle  third.     Fig.  200. 

Transverse  section,  right  leg,  lower  third.     Fig.  201. 

Transverse  section,  right  arm,  at  axilla.     Fig.  220. 

Transverse  section,  right  arm,  middle  third.     Fig.  221. 

Transverse  section,  at  right  elbow.     Fig.  223. 


PAGE 

Treves. 

535 

S.  Smith. 

536 

Treves. 

537 

Esmarch. 

538 

Esmarch. 

539 

Esmarch. 

539 

Esmarch. 

473 

Esmarch. 

474 

Kocher. 

711 

Kocher.     712 

,  713 

Kocher. 

714 

Kocher. 

715 

Kocher. 

716 

Kocher. 

717 

Kocher. 

719 

Kocher. 

151 

Kocher. 

156 

Esmarch. 

498 

Esmarch. 

499 

Treves. 

499 

Treves. 

497 

S.  Smith. 

497 

Esmarch. 

499 

Esmarch. 

498 

Wyeth. 

13 

Original. 

636 

S.  Smith. 

637 

S.  Smith. 

637 

S.  Smith. 

637 

Kocher. 

639 

Sedillot. 

640 

New. 

640 

MacCormac. 

73 

Treves. 

681 

Esmarch. 

682 

Heath,  modified. 

683 

Original. 

684 

Esmarch. 

685 

Heath,  modified. 

686 

Tillmanns. 

687 

Esmarch. 

688 

Esmarch. 

688 

Tillmanns. 

706 

Tillmanns. 

707 

Gerster. 

707 

Original. 

51 

Esmarch. 

221 

Esmarch. 

222 

Prince. 

571 

Esmarch. 

149 

Esmarch. 

152 

Esmarch,  modified. 

145 

Esmarch,  modified. 

146 

Esmarch,  modified. 

147 

Esmarch. 

153 

Esmarch. 

154 

Esmarch. 

182 

Esmarch. 

183 

Esmarch. 

185 

ILLUSTRATIONS. 


XXIX 


Fig.  224. 
Fig.  225. 


31L 


Transverse  section,  right  forearm,  upper  third. 

Transverse  section,  right  forearm,  middle  third. 

Trendelenburg's  position.     Fig.  62. 

Trendelenburg's  rod.     Fig.  92. 

Triangular  flap.      Fig.  734. 

Trifacial  nerve,  divisions  of.     Fig.  309. 

Trifacial  nerve,  second  division,  resection.     Fig. 

Trifacial  nerve,  second  division,  exposure  at  foramen  ovale 

Trifacial  nerve,  third  division.     Fig.  313. 

Trifacial  nerve,  third  division,  foramen  ovale.      Fig.  314. 

Trifacial  nerve,  Pancoast's  operation.     Fig.  315. 

Tubercle  of  os  calcis,  transplantation  of.     Figs.  357,  358. 

Tupfer,  antiseptic.     Fig.  73. 

Tying  reef  knot,  first  step.     Fig.  116. 

Tying  reef  knot,  second  step.     Fig.  117. 

Tying  reef  knot, third  step.     Fig.  118. 


PAGE 

Esmarch,  modified.  186 

Esmarch,  modified.  187 

W.  F.  lord  &  Co.  55 

W.  F.  Ford  &  Co.  75 

Treves.  588 

Gray,  modified.  278 

Kocher,  Tnodified.  281 

Fig.  312.  Kocher,  modified.  282 

Kocher.  286 

Kocher,  modified.  291 

Kocher,  modified.  292 

Chalot.  342 

Original.  63 

Heath.  83 

Heath.  83 

Heath.  83 


Upper  lip.  Buck's  method.     Figs.  780,  781. 

Upper  lip,  Sedillot's  method.     Fig.  872. 

Upper  lip,  Dieffenbach's  method.     Fig.  783. 

Upper  lip,  Szj'manowski's  method.     Fig.  784. 

Upper  and  lower  lips,  Ledran-Mackenzie  method.     Fig.  785. 

Uranoplasty,  Langenbeck's  method.     Figs.  802,  804. 

Uranoplasty,  Dieffenbach-Fergusson  method.     Fig.  805. 

Uranoplasty,  Davies-CoUey.     Figs.  806,  807. 

Uranoplasty,  Fergusson's  method.     Figs.  808,  811. 


Buck. 

Tillmanns. 

New. 

Treves. 

Terrier. 

Esmarch. 

Treves. 

Treves. 

Fergusson. 


613 
619 
614 
614 
615 
624 
625 
626 
627 


Verneuil's  method.     Fig.  730. 
Vessel  approdito.     Fig.  170. 


New. 
Original. 


585 
126 


Webbed  fingers.     Fig.  681. 

Webbed  fingers,  Norton's  operation.     Fig.  681. 

Webbed  fingers,  Diday's  operation.     Fig.  683. 

Webbed  fingers,  Agnew's  operation.     Fig.  684. 

Webbed  fingers,  Zeller's  operation.     Fig.  685. 

Webbed  fingers,  Fowler's  operation.     Figs.  686,  687. 

Whitehead's  mouth  gag  applied.     Fig.  798. 

Wiper,  antiseptic  gauze.     Fig.  73. 

Wire  serre-fine.      Fig.  103. 

Wladimirow-Mikulicz's  operation.     Figs.  431,  432. 

Wrist,  amputation  of,  circular  method.     Figs.  527,  528. 

Wrist,  amputation  at,  single  palmar  flap.     Fig.  529. 

Wrist,  amputation  at,  double-flap  method.     Figs.  530,  531. 


Wrist 
Wrist 

Wrist 
Wrist 
Wrist 
Wrist 
Wrist 
Wrist 


oint,  excision  of,  Bourgary's  method.     Fig.  412. 
oint,  excision  of,  Langenbeck's  incision.     Fig.  417. 
oint,  excision  of,  Ollier's  incision.     Fig.  417. 
oint,  excision  of,  Boeckel's  incision.     Fig.  417. 
oint,  excision  of,  subperiosteal,  Lister.     Fig.  418. 
oint,  incision,  interrupted  splint  form,  excision  of. 
oint,  Esmarch's  splint  applied.     Fig.  420. 
oint,  plaster-of-Paris  splint.     Fig.  421. 


Fig.  419. 


Gross. 

Dennis. 

Dennis. 

Dennis. 

Dennis. 

Dennis. 

Tieman. 

Original. 

W.  F.  Ford  &  Co. 

Tillmanns. 

Esmarch. 

Treves,  modified. 

Esmarch. 

Esmarch. 

Treves,  modified. 

Treves,  modified. 

Treves,  modified. 

Treves,  modified. 

Esi/iarch. 

Esmarch. 

Esmarch. 


564 
564 
565 
565 
565 
566 
622 
63 
78 
415 
477 
478 
478 
400 
403 
403 
403 
404 
405 
406 
406 


OPERATIVE   SURGERY. 


CHAPTEE  I. 

THE  GENERAL   CONSIDERATIONS. 

Operative  Surgery  treats  principally  of  the  manual  procedures  that  are 
necessary  for  the  accomplishment  of  the  surgical  object  in  view.  An  opera- 
tion in  surgery  can  be  aptly  compared  to  the  execution  of  a  verdict  in  law ; 
therefore,  as  in  legal  measures,  the  reasons  for  the  accomplishment  should 
be  based  on  a  proper  appreciation  of  the  principles  relating  to  the  procedure. 
The  surgeon,  in  most  instances,  bears  a  threefold  relationship  to  the  patient 
— viz.,  that  of  juror,  judge,  and  executor.  As  juror,  he  inquires  into  and 
determines  the  facts  concerning  the  surgical  problem  submitted  to  his  judg- 
ment, and  renders  the  verdict  according  to  the  established  truths  of  the 
case.  As  judge,  he  estimates  the  importance  of  the  facts  and  the  value  of 
the  conclusions  that  can  be  drawn  from  them,  as  based  on  the  results  of  his 
own  and  recorded  experience,  before  he  pronounces  the  decision,  for  which 
he  alone,  as  executor,  is  compelled  to  bear  the  immediate  responsibility. 

It  is  therefore  very  essential  to  the  welfare  of  the  patient  and  to  the  dig- 
nity of  the  profession  that  the  surgeon  carefully  ascertain  and  properly 
estimate  the  value  of  the  facts  relating  to  a  case  in  order  that  the  verdict  be 
a  just  one,  and  that  its  execution  does  not  needlessly  inflict  the  patient  nor 
cast  opprobrium  on  himself  or  the  profession.  The  being  competent  to 
operate  skillfully  is  not  sufficient  for  the  purposes  of  surgery ;  for  it  is  of 
great  importance  that  the  surgeon  be  qualified  to  so  fit  the  patient  and 
prepare  himself  that  no  unanticipated  complication  can  happen  during  or 
at  any  time  properly  associated  with  an  operation.  No  operation,  however 
trivial,  is  entirely  devoid  of  danger.  It  follows,  then,  that  the  surgeon  who 
treats  the  natural  apprehensions  of  patients  and  their  friends  with  indiffer- 
ence or  derision,  will  suffer  some  day  from  great  humiliation,  and  perhaps 
loss  of  professional  reputation,  because  of  an  unfortunate  result,  the  pos- 
sibility of  which  had  been  anticipated  only  by  the  friends  or  the  patient. 
While  the  surgeon  should  take  no  mercenary  advantage  of  opportunities 
born  of  the  unnecessary  though  natural  fear  of  patients  and  friends  regard- 
ing an  operation,  still  wise  forethought  on  his  part  should  not  permit  him 
to  belittle  or  conceal  the  actual  dangers  of  an  operation  when  good  judg- 
ment suggests  that  they  be  stated. 

1 


2  OPERATIVE  SURGERY. 

The  risks  of  operations  relate  chiefly  to  the  life  of  the  patient,  and  to 
the  usefulness  and  cosmetic  aspects  of  the  part  subjected  to  the  procedure. 
Urgent  conditions  demand  prompt  action ;  therefore,  in  such  as  these,  less 
heed  can  be  given  to  the  established  detail  belonging  to  deliberate  practice. 
In  acute  laryngeal  stenosis,  the  prompt  admission  of  air  to  the  lungs  is  the 
great  desideratum,  and  all  other  measures  of  treatment  must  be  subservient 
to  this  end  if  death  is  to  be  averted.  The  needs  of  both  slight  and  grave 
operations  should  receive  deliberate  thought,  even  when  the  state  of  the 
patient  is  not  suggestive  of  immediate  danger.  The  subsequent  usefulness 
of  a  part,  and  the  cosmetic  effects  of  an  operation,  ought  to  be  carefully 
weighed,  and  those  concerned  candidly  informed  of  any  unfavorable  results 
in  these  respects  that  may  follow  a  surgical  effort.  If  this  course  be  not 
observed,  the  manifestations  of  grievous  disappointment  on  the  part  of  the 
patient  and  friends  may  be  the  only  acknowledgment  willingly  bestowed  on 
the  surgeon. 

Kegarding  the  general  principles  of  surgery,  the  reader  is  referred  to  the 
many  useful  works  on  that  subject,  since  it  is  not  the  intention  of  the  author 
to  intrude  in  this  department  except  so  far  as  to  form  a  proper  estimate  of 
the  risks  arising  from  operations  and  the  best  means  of  meeting  and  of  avoid- 
ing them. 

Prior  to  an  operation,  especially  if  it  be  one  of  any  magnitude,  it  is  essen- 
tial that  the  importance  of  the  following  facts  relating  to  the  patient  be 
considered  : 

1.  The  age,  sex,  general  physical  condition,  and  occupation  of  the  patient. 

2.  If  the  patient  be  suffering  from  shock. 

3.  The  condition  of  the  heart,  lungs,  kidneys,  brain,  and  large  vessels. 

4.  If  there  be  any  acute  surgical  or  other  complication  of  an  important 
part  of  the  body.  A  coexisting  fracture,  dislocation,  severe  contusion,  or 
the  involvement  of  an  essential  viscus,  or  of  a  serous  or  bony  cavity,  often 
adds  great  gravity  to  what  might  otherwise  be  a  simple  procedure. 

5.  If  the  patient  be  anasmic,  scorbutic,  rheumatic,  hysterical,  insane,  etc. 
If  he  have  syphilis,  tuberculosis,  epilepsy,  glycosuria,  haemophilia,  malaria, 
erysipelas,  or  be  liable  to  an  attack  of  delirium  tremens. 

6.  If  he  be  willing  and  prepared  for  the  operation. 

The  Age. — As  between  youth  and  old  age,  operations  are  better  borne 
by  the  former  class.  The  most  favorable  period  is  between  five  and  fifteen 
years,  the  next  between  fifteen  and  thirty  years ;  after  the  latter  period  the 
risk  to  life  is  nearly  twice  as  great  as  during  it.  The  influences  of  the  re- 
sponsibilities, acts,  and  duties  incident  to  advancing  age  increase  the  vulner- 
ability of  the  vital  forces  in  a  marked  degree.  The  subtle  effects  of  physical 
and  mental  strain,  of  deteriorating  practices,  and  the  natural  changes  inci- 
dent to  increasing  years,  lessen  the  resisting  power  of  the  human  organism 
in  almost  a  direct  proportion  to  their  degree  and  extent.  While  youth  is 
markedly  sensitive  to  shock  and  pain,  still  the  absence  of  responsibility  and 
the  presence  of  healthy  organs  enable  this  class  to  withstand  physical  injury 
better  than  the  aged.  The  effect  of  pain,  shock,  loss  of  blood,  restlessness, 
excitability,  and  the  disarrangement  and  soiling  of  dressings,  are  the  chief 


THE  GENERAL  CONSIDERATIONS.  3 

elements  of  danger  in  the  surgery  of  children  ;  and  the  younger  the  children 
the  more  potent  are  the  effects  of  these  agencies.  Aged  patients  differ  in 
their  degree  of  endurance  from  each  other  more  than  do  the  young.  An 
aged  patient  who  has  good  muscular  and  mental  vigor,  and  is  well  nour- 
ished, not  given  to  adiposity,  has  good  digestion,  sound  organs,  and  pliable 
vessels,  is  the  best  of  this  class.  But  an  aged  patient  who  is  fat,  flabby, 
wheezy,  and  unused  to  exercise,  with  hardened  arteries,  bad  digestion,  and 
perhaps  addicted  to  the  constant  use  of  alcoholics,  is  a  poor  subject  indeed 
for  any  operation.  His  wounds  should  not  be  deep ;  his  blood  should  be 
spared ;  his  body  kept  warm  ;  his  food  of  moderate  amount  and  easily  assimi- 
lated ;  complications  should  be  watched  for,  and  the  confinement  in  bed  be 
made  as  brief  as  possible. 

The  Sex. — Women  withstand  operations  and  surgical  injuries  rather  bet- 
ter than  men.  This  difference  is  largely  due  to  the  fact  that  women  are  en- 
dowed with  a  greater  degree  of  patience  and  fortitude,  while  under  physical 
infliction,  than  men.  Confinement  to  the  house  and  in  bed  is  better  borne 
by  them,  and,  too,  they  are  more  temperate  and  discreet  in  the  customs  and 
habits  that  are  recognized  as  being  inimical  to  human  endurance.  Unless 
it  be  urgently  demanded,  it  is  unwise  to  operate  on  the  female  during  preg- 
nancy, lactation,  or  menstruation.  However,  the  gravest  of  operations  have 
been  performed  under  these  circumstances  without  the  appearance  of  an 
unfavorable  manifestation  depending  on  them. 

The  Physical  Condition. — As  a  general  proposition,  those  of  good  phys- 
ical vigor  bear  operations  better  than  those  in  a  feeble  state ;  but  one  is  not 
to  understand  that  such  is  always  the  case.  The  athlete  who  prides  himself 
on  his  strength  of  frame  and  fleetness  of  limb,  and  whose  entire  system  is 
fitted  only  for  active  effort,  is  ill  prepared  for  the  confinement  of  the  sick- 
room. The  semi-invalid  and  the  one  to  whom  confinement  brings  no  special 
regret  are,  other  things  being  equal,  better  fitted  for  the  ordeals  of  operation 
than  a  veritable  Hercules.  It  follows,  therefore,  that  those  of  the  former 
class  should,  if  expedient,  spend  a  few  days  on  probation  in  the  prospective 
sick-room,  thus  familiarizing  themselves  with  its  surroundings,  while  at  the 
same  time  their  emunctories  eliminate  the  then  useless  residue  of  an  active 
life.  The  obese  patient  is  ill  fitted  for  an  operation,  especially  if  the  obesity 
has  been  the  result  of  indolence,  luxury,  or  intemperance.  Hereditary 
obesity  is  of  less  moment  than  the  acquired  variety,  especially  when  personal 
discipline  has  been  directed  unsuccessfully  to  the  reduction  of  the  latter. 
Physiological  plethora,  fortified  by  physical  and  functional  vigor,  offers  no 
obstacle  to  surgery,  but  the  acquired  plethora  of  the  tippler  and  the  gour- 
mand serves  as  a  beacon,  warning  the  surgeon  against  all  operative  proce- 
dures unsu|)ported  by  the  logic  of  expediency  and  unprotected  by  the  strict- 
est technique. 

The  Occupation. — The  occupations  that  expose  one  to  the  depressing  in- 
fluences incident  to  mental  worry,  bad  ventilation,  and  the  inhalation  of  ir- 
ritating, offensive,  and  poisonous  gases  and  dust ;  those  also  that  expose  to 
the  direct  absorption  of  deleterious  metallic  and  other  agents,  and  that  sub- 
ject one  to  great  extremes  of  temperature,  are  not  infrequently  of  vital  im- 
3 


4.  OPERATIVE  SURGERY. 

portance  in  estimating  the  prognosis  of  operative  procedures.  The  almost 
indelible  imprint  of  the  influence  of  occupation  on  the  physical  condition  of 
patients  makes  it  unnecessary  to  do  more  than  to  refer  to  the  preceding 
special  illustrations  of  the  fact. 

The  Shock. — If  the  surgical  condition  demanding  operation  be  a  recent 
one,  and  the  patient  be  suffering  from  shock,  operation  should  be  deferred 
until  reaction  is  established,  if  wise.  If  the  degree  of  shock  be  disproportion- 
ate to  the  extent  of  the  recognized  injury,  a  further  examination  of  the 
patient  should  be  made  to  determine  the  cause.  If  a  complication  be  dis- 
covered which  of  itself  imperils  life  or  increases  the  gravity  of  the  situation, 
then  the  question  of  operation  is  doubly  perplexing,  and  the  proper  solution 
of  the  case  requires  the  sagacity  due  to  experience  or  the  judicious  fore- 
thought that  prompts  a  consultation.  A  thoughtful  scrutiny  of  those  who 
are  injured  or  diseased,  supplemented  by  proper  advisement,  will  lessen  the 
pungency  of  the  satirical  expression,  "  The  operation  was  successful,  but  the 
patient  succumbed  "  !  Shock  may  supervene  during  an  operation,  either  as 
the  result  of  the  formidable  character  of  the  procedure  or  of  the  loss  of 
blood.  The  previous  condition  of  the  patient,  the  degree  and  extent  of  the 
injury,  and  the  time  consumed  in  the  operation  are  potent  factors  bearing 
on  the  occurrence  and  the  degree  of  shock.  Shock  may  be  followed  by  syn- 
cope, syncope  by  collapse,  collapse  by  death.  In  view  of  the  importance  of 
shock  and  its  intimate  relationship  with  surgical  procedures,  a  surgeon  ought 
not  to  attempt  an  operation  unless  he  be  informed  as  to  the  symptoms  and 
the  sequels  of  shock,  their  prevention  and  their  prompt  and  effective  treat- 
ment.    (See  page  121.) 

The  Condition  of  the  Heart,  Lungs,  Liver,  Kidneys,  Brain,  and  Large 
Vessels. — Upon  the  sound  condition  of  the  viscera  depend  not  only  the  ad- 
visability of  an  operation,  but  also  of  the  choice  and  use  of  anaesthetics.  If 
the  kidneys  be  diseased,  all  operations,  especially  those  on  the  genito-urinary 
tract,  are  invested  with  special  danger.  In  the  latter  the  simplest  proce- 
dures are  followed  not  infrequently  by  fatal  suppression  of  urine  ;  therefore 
a  microscopical  and  analytical  examination  of  the  urine  should  always  be 
made  in  advance  of  an  operation  when  conditions  will  permit.  A  practical 
examination  of  the  urine  can  be  readily  made,  even  under  perplexing  cir- 
cumstances, by  the  use  of  heat  or  nitric  acid.  The  symptoms  of  such  affec- 
tions as  chronic  bronchitis,  emphysema,  phthisis,  are  often  aggravated  fey 
the  administration  of  anaesthetics,  especially  ether ;  and  the  resulting  dysp- 
noea and  cough,  loss  of  sleep  and  strength,  are  potent  influences  against 
recovery. 

It  is  well  to  remember,  however,  that  the  mental  emotion  and  physical 
suffering  often  associated  with  an  operation  without  the  use  of  ansesthesia 
may  be  more  objectionable  than  the  evil  influence  of  the  drug  itself. 

The  presence  of  chronic  dyspepsia  with  vomiting ;  organic  disease  of  the 
liver  with  icteric  manifestations ;  structural  heart  disease  with  respiratory 
interference ;  cerebral  disease — acute  or  chronic — attended  with  cephalalgia 
or  mental  or  motor  disturbances  ;  disease  of  the  arterial  system,  suggestive  of 
aneurism  or  the  difficult  control  of  haemorrhage  due  to  structural  changes  of 


THE  GENERAL  CONSIDERATIONS.  5 

the  coats ;  are  among  the  prominent  complicating  factors  of  a  case,  and  are 
deserving  of  respectful  thought  before  the  final  decision  is  rendered. 

The  Complications. — The  presence  of  complications  of  whatever  nature 
should  be  studiously  sought  for  and  their  importance  estimated  before 
operation.  It  is  unfortunate,  indeed,  that  a  patient  should  die  as  the 
result  of  a  complication,  and  especially  if  the  complication  has  not  been 
suspected  before  the  operation.  It  happens  often  that  patients  die  from 
known  complications  that  are  stimulated  to  vigorous  action  by  the  influ- 
ences belonging  to  surgical  procedures,  and  it  is  truly  sad  when  such  a 
result  follows  a  surgical  efEort  that  was  prompted  more  by  sentiment  than 
by  necessity. 

Tuieixulosis,  Syjjhilis,  and  Glycosuria. — The  influence  of  these  diseases 
on  the  prognosis  of  operations  is  modified  by  the  acuteness  and  extent  of  the 
diseased  processes,  the  ability  to  effect  their  complete  removal,  and  the  post- 
operative environments  of  the  patient.  The  removal  of  a  long-continued  and 
exhausting  site  of  scrofulous  or  tuberculous  disease — one  that  has  caused 
persistent  suffering  and  confinement  within  doors — is  often  followed  by  the 
promptest  beneficial  results,  especially  if  no  visceral  complications  have  en- 
sued and  the  patient  can  be  placed  under  favorable  sanitary  surroundings. 
Notably  this  is  true  in  children  when  complete  removal  of  the  products  of 
diseased  action  has  been  accomplished.  Incomplete  removal  of  tuberculous 
products  is  always  productive  of  questionable  results ;  in  fact,  little  is  gained 
of  local  worth  in  these  cases,  except  that  dependent  on  improved  drainage. 
The  free  opening  of  large  tuberculous  abscesses  exposes  the  patient  to  the 
danger  of  exhaustion  from  suppuration,  and  to  that  of  a  general  tuberculosis 
caused  by  the  rapid  production  and  spread  of  tuberculous  infection  through 
the  body.  Those  suffering  from  acute  or  progressive  tuberculosis  of  the 
lungs  are  unfavorable  subjects  for  any  operation  that  excites  apprehension 
or  requires  the  use  of  anaesthetics.  Operations  on  such  subjects  as  these  are 
rarely  permissible,  except  to  lessen  the  burden  already  imposed  by  disease, 
and  thereby  to  husband  the  strength  of  the  patient,  that  he  may  better  resist 
the  continued  infliction.  Though  the  wounds  of  chronic  tuberculous  pa- 
tients often  heal  quickly  and  well,  still  they  may  refuse  to  unite,  or,  after 
unsound  union,  reopen  and  become  the  source  of  great  exhaustion.  The 
wounds  of  syphilitic  patients  commonly  heal  well.  Although  the  reverse  of 
this  result  is  rare,  yet  one  is  not  justified  in  attempting  local  surgical  meas- 
ures in  these  cases  without  the  previous  employment  of  constitutional  specific 
medication,  if  circumstances  will  permit. 

In  glycosuria,  wounds  heal  badly  and  sometimes  not  at  all,  and  the  occur- 
rence of  cellulitis  and  gangrene  are  often  provoked  by  operative  measures. 
The  results  of  preparatory  treatment  are  fickle,  as  a  rapid  increase  in  sugar 
without  apparent  cause  while  under  seemingly  curative  treatment  frequently 
happens.  Operations  with  this  complication,  if  it  be  pronounced,  should  be 
those  of  last  resort,  and  every  chance  of  infection  eliminated  in  all  cases. 

Patients  afflicted  with  rheumatism  or  gout  are  good  subjects  for  opera- 
tion, provided  heart  and  kidney  complications  are  not  present,  or,  if  so,  not 
well  established.    However,  it  should  not  be  forgotten  that  the  inaction  of 


6  OPERATIVE  SURGERY. 

the  patient  and  of  his  secretions  resulting  from  the  confinement  incident  to 
an  operation  may  soon  provoke  an  attack  of  either  of  these  diseases. 

Hcemopliilia,  Scurvy,  and  Leucocythcemia. — In  any  one  of  these  condi- 
tions no  operation  should  be  performed  except  from  absolute  necessity,  as 
they  each  expose  the  patient  to  death  from  uncontrollable  haemorrhage,  the 
first  being  especially  fatal  in  this  respect.  It  is  important  to  know,  however, 
that  in  haemophilia  one  may  not  meet  with  fatal  haemorrhage,  even  after 
severe  operations.  Leucocythaemia,  scurvy,  and  icterus  not  only  predispose 
to  severe  and  perhaps  fatal  haemorrhage,  but  in  addition  to  this  wounds  of 
those  afflicted  with  the  first  two  diseases  suppurate  profusely,  heal  badly, 
and  often  remain  unclosed. 

The  statements  of  patients  that  they  are  "  bleeders  "  should  not  be  ac- 
cepted as  final  in  instances  of  emergency  without  confirmatory  evidence. 
Not  long  ago  the  author  had  a  patient  with  a  pelvic  abscess  due  to  appendi- 
citis, and  who  opposed  operation  because  he  had  been  assured  by  a  physician 
a  short  time  before  that  he  was  a  "  bleeder."  The  statement  was  proved 
untrue  for  the  time  by  making  a  short  incision  in  the  integument  at  the  seat 
of  the  proposed  operation,  which  incision  healed  quickly  without  an  un- 
toward symptom.  Promptly  thereafter  the  operation  was  done  and  the 
patient  recovered  in  a  most  uneventful  manner.     (See  page  67.) 

Malaria. — Malarial  poisoning  often  hinders  healing,  and  predisposes  to 
suppuration,  inflammation,  and  neuralgia.  An  operation  sometimes  arouses 
latent  malaria  attended  with  febrile  manifestations  peculiar  to  itself,  and  if 
its  nature  be  not  recognized  will  cause  the  surgeon  great  apprehension  lest 
they  be  the  result  of  septic  influences. 

Erysipelas. — No  avoidable  operation  should  be  performed  in  the  pres- 
ence of  erysipelatous  influences.  If  the  surgeon  be  driven  to  this  extremity, 
the  most  rigid  antiseptic  measures  should  be  enforced.  Patients  with  stran- 
gulated hernia,  retention  of  urine,  a  crushed  limb,  and  the  like,  require  relief, 
and  the  surgeon  must  act  promptly  to  save  life,  irrespective  of  conflicting 
demands. 

Insane,  hysterical,  and  epileptic  persons  are  not  good  surgical  subjects,  as 
they  are  ill  fitted  to  submit  to  the  control  essential  to  prompt  and  proper 
healing ;  moreover,  their  physical  status  is  deteriorated  and  quite  unrespon- 
sive to  local  and  general  medication,  in  many  instances. 

Alco7iolis7n. — A  person  who  is  addicted  to  the  continuous  use  of  intoxi- 
cating beverages  is  a  bad  surgical  patient,  and,  worse  still,  if  he  receives  an 
injury  during  a  prolonged  debauch,  as  then  he  suffers  not  only  from  the 
effects  of  the  previous  excesses,  but  incurs  a  greater  danger  of  delirium 
tremens. 

Willing  and  Prepared. — It  is  not  necessary  to  the  successful  issue  of  an 
operation  that  the  patient  be  willing  and  prepared  for  it ;  yet,  if  such  be  the 
case,  much  will  be  added  to  the  ultimate  success  of  the  measure.  If  he  be 
irresponsible  by  reason  of  childhood  or  incompetent  mental  state,  others  who 
are  accountable  for  or  interested  in  him  should  be  consulted.  The  approval 
by  himself  or  those  concerned  should  be  accepted  only  after  a  clear  statement 
on  the  part  of  the  surgeon  of  the  nature  of  the  injury  or  disease,  the  necessity 


TUB   GENERAL   CONSIDERATIONS.  7 

for  and  the  gravity  of  the  operation,  together  witli  the  prohable  result  of  the 
procedure.  If  the  operation  be  a  momentous  one,  the  advisability  of  the 
adjustment  of  business  and  spiritual  affairs  should  be  suggested  to  the  pa- 
tient himself  or  to  the  friends.  The  satisfactory  arrangement  of  such  mat- 
ters will  reconcile  the  patient  to  his  trials,  and  be  a  cause  of  satisfaction  to 
the  friends  in  any  event.  The  preparatory  treatment  should  be  directed  to 
improving  the  general  condition  of  the  patient,  either  by  proper  diet  or  by 
medication  intended  to  antagonize  the  diseases  and  conditions  that  may  pre- 
judice the  final  result.  The  patient  must  be  thorougUy  examined  in  every 
material  respect  before  an  operation  is  undertaken  in  order  to  determine  his 
actual  physical  status.  It  is  unwise,  if  unnecessary,  to  operate  precipitately; 
rather  allow  the  patient  to  familiarize  himself  with  the  surroundings  by  re- 
maining in  the  room  for  a  time,  and  in  bed  even,  if  it  adds  to  his  comfort. 
After  careful  physical  examinetion  the  patient  should  be  bathed,  and 
warmly  clad,  the  bowels  should  be  moved,  the  face  shaven,  the  hair  combed 
and  neatly  arranged,  and  the  temperature,  pulse,  and  respiration  taken  well 
in  advance  of  the  time  of  operation ;  also  carefully  examine  the  blood. 

The  Time  for  Operation. — The  proper  time  for  operation  refers  to  the 
season  of  the  year,  the  day  and  the  time  of  day  best  suited  for  the  purpose. 
It  is  fortunate,  indeed,  for  all  concerned  when  circumstances  will  permit  the 
selection  of  the  time  that  will  contribute  the  greatest  advantages  to  every 
interest  connected  with  the  case.  Often,  however,  the  urgency  of  the  occa- 
sion commands  prompter  action,  affording  only  sufficient  time  to  make  the 
immediate  preparations  referable  to  the  patient  and  his  surroundings  and 
to  the  surgeon  himself.  At  all  events,  the  exact  time  should  be  settled  and 
the  engagement  promptly  kept.  A  surgeon  should  not  ever  he  lacl'ing  in 
punctuality  on  these  occasions.  Many  patients  regard  operative  procedures 
on  themselves  with  a  degree  of  dread  akin  to  that  felt  by  a  culprit  whose 
time  for  punishment  is  fast  approaching;  and,  too,  they  fix  the  time  when 
the  operation  will  be  completed  and  themselves  safely  started  on  the 
road  to  recovery.  Therefore,  a  needless  delay  disturbs  their  calculations, 
often  arouses  their  superstition,  defers  and  lessens  their  hopes,  and  per- 
haps destroys  their  courage,  an  element  of  great  importance  to  successful 
issues. 

The  months  of  October,  January,  and  April  are  regarded  as  the  most 
favorable  for  operation;  December,  May,  and  November  as  the  most  un- 
favorable. In  general  terms,  spring  and  autumn  are  the  most  favorable  sea- 
sons. A  cool,  pleasant  day  with  rising  barometer  and  minimum  humidity  is 
best  suited  for  the  purpose.  The  hour  of  early  morning  is  best,  as  then  the 
light  is  ample,  the  time  of  worry  limited,  and  the  need  for  food  avoided. 
However,  there  is  no  reason  to  believe  that  the  advantages  of  selected 
months  exercise  as  great  influence  on  operative  results  as  do  other  well- 
heeded  opportunities  and  requirements,  having  but  little  bearing  on  the 
time  or  humidity  of  the  day. 

The  Place  for  Operation. — The  office  of  the  surgeon  is  not  the  proper 
place  to  perform  operations  of  any  magnitude  nor  those  requiring  the  use  of 
an  anaesthetic,  because  the  rest  and  quiet  that  should  follow  can  not  be  had 
if  the  patient  be  removed ;  and,  moreover,  anaesthesia  is  often  succeeded  by 


8  OPERATIVE  SURGERY. 

persistent  nausea  and  vomiting,  and  not  infrequently  by  prolonged  noisy 
delirium.  In  a  private  residence  the  room  for  operation  should  adjoin  the 
sick-room,  and,  if  possible,  be  convenient  to  the  water  supply.  The  room 
should  be  thoroughly  cleansed  by  scrubbing  the  floor  and  walls,  and  wiping 
the  ceiling  and  above  the  doors  and  windows  with  a  dampened  cloth.  Fumi- 
gation with  sulphur  will  not  be  amiss,  unless  it  be  employed  to  the  exclusion 
of  the  preceding  measures.  Needless  articles  should  be  removed  and  others 
made  aseptic,  or  be  covered  with  aseptic  sheets.  Clean  linen  and  blankets 
should  be  at  hand.  A  good  light  should  be  secured  and  unwelcome  observa- 
tion from  without  excluded.  The  preparation  of  the  room  should  be  com- 
pleted in  time  to  permit  the  settling  of  dust  before  operation.  If  the  room 
can  be  disconnected  from  the  living  rooms  of  the  dwelling,  the  occupants 
will  be  spared  the  distress  and  annoyance  arising  from  the  noises  and  odors 
incident  to  the  operation. 

The  Sick-room. — The  sick-room  should  be  commodious,  sunny,  and  asep- 
tic, and,  when  possible,  on  the  second  floor,  with  a  southern  exposure,  and 
with  the  doors  and  windows  so  arranged  that  it  can  be  easily  ventilated 
without  causing  objectionable  air  currents.  All  sewer-connected  wash  basins 
or  other  receptacles  of  waste  should  be  excluded  from  the  room.  The  plainer 
the  walls  and  ceilings  the  better,  for,  if  the  patient  becomes  delirious,  the 
outlines  and  figures  of  decorations  may  invite  and  become  the  basis  of  ex- 
citing hallucinations.  It  is  better  at  all  times — for  hygienic  reasons — that 
the  room  be  as  plain  as  possible,  and  that  all  unnecessary  articles,  as  car- 
pets, etc.,  be  removed  therefrom.  The  bed  should  be  single,  with  freshly- 
aired  linen,  and  have  a  rubber  cloth  beneath  the  sheet  if  needed.  During 
convalescence,  and  after  all  dangers  from  septic  influences  are  passed,  objects 
of  interest  may  be  placed  upon  the  mantels  and  walls,  which  can  be  varied 
from  time  to  time  to  please  the  fancies  of  the  patient.  The  room  should  be 
made  as  cheerful  as  possible,  consequently  all  annoyances  should  be  removed 
whenever  the  fancies  of  the  patient  indicate  their  presence.  The  presence 
in  the  sick-room  of  flowers  and  other  odoriferous  agents  are  not  to  be  en- 
couraged, although  they  may  exert  a  good  moral  influence  in  that  they 
remind  the  patient  of  the  existence  of  sympathizing  friends  without. 

The  temperature  of  the  room  should  be  maintained  at  about  70°  F.  Pure 
air  is  quite  as  essential  to  a  rapid  recovery  as  good  food.  The  room  should 
be  thoroughly  ventilated  at  least  once  each  day.  Ventilation  can  be  readily 
secured  by  opening  the  windows  and  doors,  thereby  creating  a  through-and- 
through  current,  at  the  same  time  using  caution  that  the  patient  be  pro- 
tected from  direct  draughts,  and  be  well  covered  till  the  temperature  shall 
have  resumed  a  suitable  standard. 

The  subsequent  care  of  the  room  calls  for  scrupulous  cleanliness,  the 
prevention  of  offensive  odors,  and  the  prompt  elimination  of  foul  and  disa- 
greeable matters.  Dusting  should  not  be  done  without  dampening  the  sur- 
faces with  an  antiseptic  fluid  when  practicable ;  and  sufficient  time  should 
elapse  after  the  dusting  to  permit  the  subsidence  of  the  disturbed  particles 
before  the  wound  is  exposed.  All  unnecessary  articles  causing  or  collecting 
dust  should  be  kept  away  from  the  room  until  the  wound  is  closed. 


TPIE  GENERAL  CONSIDERATIONS.  9 

The  Nursing. — The  services  of  trained  nurses  are  the  most  reliable,  for 
not  only  are  they  familiar  with  the  common  details  of  the  sick-room,  but  they 
are  educated  also  to  meet  emergencies  of  unusual  character,  as  secondary 
hfemorrhage,  etc.  The  well-intended  attentions  and  efforts  of  solicitous 
friends  are  often  misleading  to  the  surgeon  as  well  as  burdensome  to  the 
patient.  Friends,  too,  are  quite  as  apt  to  be  controlled  in  their  actions 
by  the  desires  of  the  patient  as  by  the  expressed  directions  of  the  medi- 
cal attendant.  It  is  well  to  remember,  however,  that  a  discreet  friend  is  a 
far  better  attendant  than  a  garrulous,  self-suJBQcient  nurse.  The  attendant 
who  proffers  his  views  and  airs  his  experience  in  the  sick-chamber,  hoping 
thereby  to  emphasize  his  attainments,  is  as  detrimental  to  the  moral  atmos- 
phere of  the  room  as  are  closed  windows  and  doors  to  the  physical. 

The  Diet. — Precisely  the  variety  and  amount  of  food  to  be  given  are 
matters  which  must  be  determined  by  the  requirements  of  the  individual 
cases.  Milk,  eggs,  milk  punch,  kumyss,  and  stimulants,  are  stereotyped  arti- 
cles, the  usefulness  of  which  is  well  established.  The  traditional  beef  tea 
and  the  elaborate  chemical  extracts  with  which  the  market  is  cloyed  should 
not  be  substituted  for  them  without  special  reasons. 

The  Requirements  relating  to  Operations. — The  requirements  necessary 
to  the  attainment  of  commendable  results  may  be  divided  into  the  essential 
and  precautionary. 

The  essential  requirements  comprise  the  implements,  agents,  and  in- 
formation necessary  to  the  proper  performance  of  an  operation,  and  a  due 
consideration  as  to  the  probable  result. 

The  jyreccmtionary  requirements  are  those  which  are  needful  in  the  vari- 
ous emergencies  that  may  complicate  an  operation ;  and  if  they  become 
of  practical  utility,  it  is  necessary  that  the  emergencies  be  anticipated,  and 
that  the  means  to  meet  them  be  at  hand  and  prepared  for  immediate  use. 

THE   ESSENTIAL   REQUIEEMENTS. 

1.  A  knowledge  of  the  results  of  the  operation  to  be  performed,  as  modi- 
fied by  the  patient's  condition  and  the  emergencies  liable  to  occur. 

2.  A  knowledge  of  the  anatomy  of  the  parts  involved  in  the  operation. 

3.  The  anaesthetics;  a  proper  knowledge  of  their  administration  and 
the  combating  of  their  dangers.     (See  page  16.) 

4.  The  necessary  instruments,  and  a  knowledge  of  their  use. 

5.  The  suitable  receptacles  to  contain  instruments. 

6.  The  operating  table,  sponges,  "  wipers,"  "  tupfers,"  antiseptic  pads,  anti- 
septic solutions,  rubber  cloths,  towels,  sheets,  emjDty  vessels,  etc. 

7.  The  agents  for  controlling  hgemorrhage. 

8.  The  assistants,  of  suitable  number  and  proficiency. 

9.  The  proper  preparation  of  the  patient  and  surgeon,  table,  assistants, 
nurses,  etc.,  for  the  operation. 

10.  The  proper  materials  for  the  treatment  of  operation  wounds,  and 
a  knowledge  of  their  use. 

A  Tcnoivledge  of  the  results  of  the  operation  to  he  performed  as  modified 
hy  the  patienfs  condition  and  the  emergeiicies  liable  to  occur,  is  one  of  the 


10  OPERATIVE  SURGERY. 

chief  factors  to  be  regarded  in  the  determination  of  operative  propriety,  and 
is  therefore  entitled  to  primary  consideration.  This  knowledge  is  gained 
from  but  three  sources :  First,  from  the  personal  experience  of  the  opera- 
tor ;  second,  from  the  judgment  of  others  present ;  third,  from  the  recorded 
experience  of  the  profession.  The  utilization  of  the  second  source  implies 
the  calling  of  a  consultation,  which  should  be  done  whenever  a  doubt  ex- 
ists in  the  mind  of  the  surgeon  regarding  the  nature  or  the  result  of  an 
operation.  This  course  not  only  offers  to  the  patient  every  available  chance 
for  life  and  usefulness,  but,  in  unfortunate  results,  it  frequently  soothes 
the  feelings  of  disappointment  experienced  by  all  concerned.  In  every 
instance  the  surgeon  should  heed  the  teachings  of  the  recorded  experience 
of  the  profession,  which  record,  being  modified  from  year  to  year  by  prac- 
tice and  improved  methods,  to  be  of  commendable  utility  should  be  recent. 

An  under stayidiJig  of  the  anatomy  of  the  part  involved  in  an  oper- 
ation is  always  essential  to  the  comfort  of  the  operator,  and  frequently 
to  the  safety  of  the  patient.  This  knowledge  is  somewhat  difficult  to 
acquire,  and  is  always  of  uncertain  tenure.  In  the  instance  of  the  general 
practitioner  it  consists  largely  of  that  which  can  be  gained  from  text-books 
and  anatomical  plates,  added  to  the  anatomical  knowledge  retained  since 
graduation.  Those  who  reside  near  to  and  in  large  cities  should  avail 
themselves  of  the  ample  opportunities  offered  there  to  rehearse  on  the 
cadaver  important  operations. 

The  AncBsthetics. — The  ansesthetics  in  established  use  are  ether,  chlo- 
roform, A.  C.  E.  mixture,  and  nitrous  oxide  or  laughing  gas.  The  practical 
use  of  ansesthesia  comprehends  the  selection  of  the  anagsthetic,  the  prepa- 
rations for  anaesthesia,  the  methods  of  administration,  and  the  treatment 
of  the  complications  incident  to  their  employment.  Ordinarily  the  condi- 
tion of  the  patient  and  the  character  and  length  of  the  operation  will  deter- 
mine the  selection  of  the  anaesthetic.  It  not  infrequently  happens,  however, 
that  the  surgeon  is  obliged  to  act  in  such  matters  irrespective  of  established 
rules,  and  even  in  opposition  to  his  own  judgment,  owing  to  inadequate  sup- 
ply or  adverse  environment.  The  circumstances  regulating  the  general 
employment  of  individual  angesthetics,  together  with  the  complications  pe- 
culiar to  their  use,  will  be  indicated  in  connection  with  the  consideration 
of  the  individual  drugs.  The  physical  condition  of  the  patient  should  be 
carefully  scrutinized  in  all  respects,  to  ascertain  if  he  be  subject  to  any 
special  danger  from  ansesthesia  or  from  the  use  of  an  especial  ansesthetic. 
Much  has  been  said  already  under  the  physical  condition  of  the  heart, 
lungs,  etc.,  bearing  on  this  question,  and  on  account  of  the  importance  more 
will  be  added  in  connection  with  the  detailed  consideration  of  special 
angesthetics. 

The  Preparations  for  Ancesthesia. — The  preparations  relate  to  those  di- 
rected to  the  patient  and  to  the  administrator  of  the  anaesthetic. 

HOW   TO    PREPARE    A    PATIENT   FOR   ANESTHESIA. 

1.  Determine  as  to  the  healthful  condition  of  the  brain,  heart,  lungs, 
kidneys,  and  vessels,  and,  if  disease  be  found,  inform  the  patient  or  friends 


THE   GENERAL  CONSIDERATIONS.  H 

of  any  additional  danger  incurred  from  the  use  of  the  anaesthetic.  Admin- 
ister to  the  patient  at  once  the  necessary  remedies  to  forestall  or  mitigate 
the  danger — as  digitalis,  strychnin,  etc.,  in  the  instance  of  heart  disease. 

2.  Make  a  record  of  the  pulse  and  respiration  ;  note  the  character  of  each, 
making  due  allowance  for  any  excitement  caused  by  surrounding  circum- 
stances ;  also  the  temperature — the  rectal  and  vaginal  are  the  most  reliable. 
These  observations  will  be  much  more  trustworthy  if  they  be  made  some 
time  prior  to  the  operation.     A  note  of  arterial  pressure  is  often  important. 

3.  Ascertain  if  solid  food  has  been  taken  for  six  to  eight  hours  before 
the  operation ;  if  so,  either  defer  the  operation  or  evacuate  the  stomach 
before  giving  the  anaesthetic.  The  practical  manner  of  meeting  this  indica- 
tion is  to  omit  the  meal  immediately  preceding  the  operation.  If  the  time 
be  then  too  long,  a  glass  or  two  of  milk,  or  other  suitable  liquid  food,  five 
or  six  hours  before  will  suffice.  It  is  wise  to  remember  that  the  apprehen- 
sion of  the  patient  may  so  hinder  digestion  as  to  give  rise  to  objectionable 
emesis  even  with  these  precautions. 

4.  If  false  teeth  be  in  place,  remove  them,  also  anything  that  might  be- 
come dislodged  and  obstruct  the  larynx  or  oesophagus. 

5.  Loosen  all  constricting  bands  that  surround  the  abdomen,  chest,  or 
throat. 

6.  Cause  the  evacuation  of  the  bladder  and  rectum ;  this  precaution  will 
often  prevent  the  patient  soiling  the  clothes  during  anaesthesia. 

7.  Place  the  patient  on  the  back  with  the  head  and  shoulders  raised 
slightly,  neck  not  bent.  If  the  patient's  co-operation  be  needed  to  place 
the  body  properly  for  operation,  then  it  may  be  advisable  to  administer  the 
anesthetic  from  the  outset  with  the  patient  in  the  required  position. 

8.  If  the  patient  have  a  beard,  it  should  be  thoroughly  wet,  to  prevent 
the  escape  of  ether  through  it  from  beneath  the  cone. 

9.  So  adjust  the  doors  and  windows  as  to  admit  fresh  air  without  ex- 
posing the  patient  to  draughts. 

10.  Endeavor  to  relieve  the  patient  of  any  fear  of  danger  attending  the 
use  of  the  ansesthetic.  Patients  who  are  disturbed  by  grave  apprehensions 
or  inconsistent  fancies  regarding  the  outcome  of  angesthesia  do  not  usually 
yield  readily  and  satisfactorily  to  its  influence. 

Struggling  patients  should  not  be  forcibly  restrained,  unless  their  efforts 
interfere  with  the  administration  of  the  anesthetic,  or  there  be  danger  that 
they  will  injure  themselves.  The  means  of  restraint  employed  for  such  pa- 
tients is  manual,  and  may  require  not  less  than  four  assistants  for  proper  exe- 
cution (Fig.  1).  The  hands  nearest  to  the  head  of  the  patient,  of  the  assist- 
ants, should  be  placed  respectively  on  the  shoulders  and  pelvis  of  the  patient, 
and  the  disengaged  hands  should  grasp  correspondingly  the  upper  and  lower 
extremities  of  the  respective  sides  of  the  body.  When  thus  arranged  the 
control  of  a  resisting  patient  with  a  minimum  outlay  of  strength  is  readily 
attained.  A  rational  control,  instead  of  an  absolute  confinement  of  the  pa- 
tient's efforts  by  any  physical  means,  is  the  wiser  and  safer  plan.  At  all 
events,  the  operating  surgeon  should  not  tax  his  muscular  strength  and  nerve 
command  in  the  efforts  to  restrain  a  rebellious  patient,  for  obvious  reasons. 


12  OPERATIVE  SURGERY. 

Coughing  and  swallowing  in  the  early  stages  of  anaesthesia  indicate  that 
the  vapor  is  too  strong,  therefore  it  should  be  temporarily  modified  in  in- 
tensity by  the  admission  of  air.     If  coughing,  swallowing,  or  vomiting  hap- 


PiG.  1. — A  method  of  restraint. 

pen  during  the  later  stages  of  anaesthesia,  it  indicates  returning  conscious' 
ness,  due  to  the  employment  of  an  inadequate  amount  of  the  ansesthetic,  and 
a  prompt  increase  is  demanded  in  order  to  avoid  the  annoyance  and  delay 
incident  to  vomiting.  Eepeated  acts  of  swallowing  during  the  later  stages 
of  anaesthesia  are  often  followed  promptly  by  vomiting,  hence  the  ansesthetic 
should  be  "  pushed  "  at  once  to  avoid  this  unpleasant  result. 

How  to  prepare  the  Adfninistrator  of  an  Anmsthetic. — Often,  indeed, 
too  little  importance  is  attached  to  the  giving  of  an  anaesthetic.  This  post 
of  responsibility  is  slighted  when  it  is  permitted  to  be  occupied  by  one  not 


THE  GENERAL  CONSIDERATIONS. 


13 


thoroughly  competent  to  judge  promptly  and  accurately  of  the  effects  of 
anaesthetics,  and  qualified  to  apply  at  once  the  necessary  means  to  neutralize 
any  unfavorable  influences  caused  by  them.  The  common  custom  of  most 
hospitals  in  this  coun- 
try assigns  the  giving 
of  the  anajsthetic  to  the 
junior  member  of  the 
staff.  I  am  convinced 
that  this  practice  is 
open  to  serious  objec- 
tion, as  it  happens  not 
infrequently  that  the  proper  giving  of  the  anaesthetic  is  a  matter  of  greater 
moment  than  the  performance  of  the  operation  demanding  its  use.  At  all 
events,  I  feel  justified  in  saying  that  a  perfunctory  selection  of  one  to  give 
an  anaesthetic  is  always  an  injudicious  act,  even  though  the  protecting  influ- 


FiG.  2. — Mathieu's  tongue-holding  forcep 


Fig.  3. — Drawing  tongue  forward. 

ence  of  Nature's  limitless  resources  interposes  often  in  these  cases,  and  con- 
verts that  which  might  be  an  unfortunate  disaster  into  a  surprisingly  good 
result.  The  administrator  of  an  angesthetic  should  have  at  his  quick  com- 
mand a  tongue  forceps,  mouth  gag.,  basin  and  towel,  sponges  and  sponge 
liolders.  The  tongue  for- 
ceps used  for  grasping 
and  drawing  the  tongue 
forward  (Fig.  3)  should 
be  so  constructed  as  to 
cause  the  least  possible 
injury  to  the  organ  (Fig. 
2).  The  seizing  of  the 
tongue  with  ordinary  for- 
ceps, or  forci-pressure,  as 
one  not  infrequently  ob- 


FiG.  4. — Denhard's  mouth  gag. 


serves,  inflicts  a  needless  amount  of  injury,  and  subjects  the  patient  to  un- 
necessary suffering.  Tlie  mouth  gag  (Fig.  4)  should  be  of  such  a  pattern  as 
will  admit  of  easy  introduction  between  the  closed  teeth,  as  it  frequently 
happens  that  the  patient  will  vomit  with  clenched  jaws,  and  therefore  will 


14 


OPERATIVE  SUEaERY. 


Fig.  5. — Hard-rubber  oi'al  mti".v. 


Fig.  6. — Woudeii  jaw  pry. 


be  in  greater  peril  than  otherwise  from  the  inhalation  of  vomited  matter ; 
a  hard-rubber  oral  screw  can  be  used  for  this  purpose  (Fig.  5).  A  round 
pine  stick  of  suitable  size  and  strength,  and  properly  pointed,  can  be  in- 
serted between  the  teeth  more  easily  than  any  other  agent,  and  without 
breaking  the  teeth  or  lacerating  the  gums,  as  occasionally  occurs  when  for- 
cible or  hasty  efforts  are  made  to  separate  the  jaws  with  a  metallic  imple- 
ment. Fig.  6  illustrates  the 
one  used  for  many  years  by  the 
author.  The  hasin  is  for  the 
reception  of  vomited  matter, 
and  the  towel  to  wipe  away 
the  saliva  and  vomit  from  the 
mouth.  If  saliva  collects  in  the 
pharynx  of  sufficient  amount  to 
impede  respiration,  it  should  be  wiped  out  with  sponges  held  by  a  sponge 
holder  or  forceps  (Fig.  7).  It  is  very  important  that  the  sponge  be  securely 
held  during  the  wiping,  since  not  infrequently  it  has  been  torn  loose  while 
in  the  pharynx,  quickly  drawn  into  the  larynx,  and  caused  the  death  of 

the  patient  in  spite  of 


every  effort  at  removal. 
hi  addition  to  the  pre- 
ceding agents,  there 
should  be  near  at  hand 
and  prepared  for  in- 
stant use  a  hypodermic  syringe,  nitrite  of  amyl  capsules,  brandy,  ammonia; 
also  suitable  preparations  of  camphor,  caffein,  musk,  strychnin,  digitalis, 
etc.,  for  hypodermic  use.  The  practice  of  injecting  ether  can  not  be  com- 
mended in  ether  anaesthesia,  not  only  on  account  of  the  local  irritation  and 
pain  which  it  produces,  but  because  it  logically  contributes  to  the  depres- 
sion already 
present.  The 
Fig.  7. — Sponge  holder  and  sponge.  employment 

of  alcoholic 
injections  under  these  circumstances  is  not  wise,  owing  to  the 
chemical  and  physiological  affiliations  of  ether  and  alcohol,  and 
certainly  not  if  the  use  of  other  cardiac  stimulants  be  practi- 
cable. The  employment  of  stimulating  hypodermic  injections  in  connection 
with  anaesthesia  is  much  more  common  than  formerly,  and  the  necessity  for 
it  is  not  clearly  apparent;  therefore  there  is  good  reason  to  regard  the  in- 
creasing tendency  with  disfavor.  Adrenalin  for  injection  should  be  at  hand. 
During  the  administration  of  the  ancesthetic  the  giver  should  watch  care- 
fully the  respiration,  pulse,  and  facies  of  the  patient.  The  character  of  the 
respiration  can  be  estimated  by  the  respiratory  sounds  and  the  abdominal 
and  chest  movements;  the  pulse,  by  the  carotid  and  temporal  pulsations; 
the  facies,  by  the  color,  as  whether  pallid,  florid,  livid,  etc.,  remembering 
that  with  each  ansesthetic  it  should  be  possible  to  cause  unconsciousness 
without  cyanosis,  and  that  any  practical  method  characterized  by  its  occur- 


THE  GENERAL  CONSIDERATIONS. 


15 


rence  is  open  to  serious  objection.  The  relations  of  the  patient  and  the  ad- 
ministrator of  the  anjesthetic  are  such  that  he  can  easily  estimate  both  the 
carotid  and  temporal  pulsations  without  special  effort,  and  also  can  push 
the  jaw  forward  (Fig.  8)  readily  while  holding  the  inhaler  in  a  proper  posi- 
tion. It  is  quite  a  common  practice  now  to  push  the  jaw  forward  con- 
tinuously during  the  entire  administration  of  the  anesthetic.  This  is  un- 
necessary, as  the  pressure  may  serve  no  special  purpose,  except  during 
profound  anaesthesia;  and  a  too  persistent  and  vigorous  use  of  force  not 
only  fatigues  the  anesthetist,  but  also  lames  the  patient's  jaw. 

Complete  quietude  on  the  part  of  all  present  should  be  maintained, 
since  conversation  often  stimulates  the  patient's  inebriated  fancies,  causing 
them  to  form  the 
basis  of  disorderly  ac- 
tions. The  handling 
of  the  part  to  be 
operated  on  prior  to 
complete  insensibility 
is  a  fertile  source  of 
disturbance,  and  is 
often  suggestive  to 
the  patient  of  a  pre- 
mature beginning  of 
the  operation.  The 
preparation  of  the 
site  of  operation  early 
in  the  administration 


Fig.  8. — Pushing  ]aw  forward. 


of  the  anaesthetic  not  only  delays  the  effect  of  the  drug  by  disturbing  the 
patient  and  exciting  his  fears,  but  it  also  increases  the  amount  necessary 
for  proper  anesthesia. 

The  Dangers  from  the  Use  of  Ancesthetics. — The  dangers  attending  the 
use  of  an  anesthetic  may  be  reduced  to  a  minimum.,  provided  proper  at- 
tention be  given  to  the  physical  conditions  recognized  as  contra-indicating  it 
or  requiring  in  all  respects  caution  in  the  administration.  The  control- 
ling influences  in  the  selection  of  the  anesthetic  will  appear  under  the 
consideration  of  the  uses  of  the  individual  agents. 

In  complete  anesthesia  the  pupils  are  variable,  pulse  is  full,  soft,  regular, 
and  perhaps  accelerated ;  the  respiratory  acts  are  quickened,  the  inspirations 
deepened,  and  stertor  is  usually  present;  the  muscles  are  relaxed,  and  re- 
flex action  is  quite  abolished.  Hie  reflexes  that  are  heeded  as  guides  in  anes- 
thesia are  four  in  number — viz.,  the  movements  of  the  limbs  incited  by  irri- 
tation, as  when  caused  by  pinching  or  pricking  the  skin,  and  also  relaxation, 
as  demonstrated  by  flexion  and  extension  without  muscular  opposition; 
spasm  of  the  orbicularis  muscle  of  the  eye  when  the  conjunctiva  is  touched ; 
the  reflexes  of  cough  and  deglutition  stimulated  by  the  presence  of  mucus 
and  of  the  vapor  in  the  throat,  larynx,  etc.  The  conjunctival  reflex  test  is 
the  one  commonly  applied  to  determine  advancing  or  receding  conscious- 
ness.    It  is  especially  useful  for  this  purpose,  since  it  is  the  last  of  the  re- 


16  OPERATIVE  SURGERY. 

flexes  to  disappear  and  the  first  to  reappear  during  angesthesia.  Dilated 
and  fixed  pupils  indicate  excessive  anaesthesia.  The  anaesthesia  for  the  un- 
interrupted performance  of  operations  on  the  mouth,  rectum,  and  genito- 
urinary organs  should  be  of  a  greater  degree  at  the  outset  than  for  opera- 
tions on  other  portions  of  the  body,  owing  to  the  interference  with  continuous 
administration  in  the  first  instance,  and  to  the  greater  sensibility  of  the 
parts  in  the  latter  instances.  Since  it  appears  that  death  happens  with  com- 
parative frequency  in  trivial  operations,  with  incomplete  anaesthesia,  the  full 
effects  of  the  drug  should  be  secured  before  an  operation  is  commenced. 

It  is  difficult  sometimes  to  secure  complete  anaesthesia — a  fact  that  causes 
much  annoyance  and  not  a  little  trepidation  on  the  part  of  the  surgeon. 
This  incident  is  commonly  dependent  on  timid  or  inexperienced  adminis- 
tration, or  the  use,  perhaps,  of  an  inadequate  amount  of  the  anaesthetic. 
The  known  likelihood  of  this  difficulty  in  a  patient  requires  a  careful  use 
of  the  drug,  and  a  ready  and  thorough  knowledge  of  the  dangers  and  the 
methods  of  meeting  and  averting  them.  Patients  who  are  feeble,  aged, 
anaemic,  suffering  from  shock  and  the  benumbing  influences  of  narcotics, 
yield  quickly  to  anaesthetics,  and  for  this  reason  corresponding  care  should 
be  exercised.  The  ear  of  the  administrator  should  attend  keenly  to  the 
respiratory  sounds,  noting  carefully  all  variations  in  their  intensity  and 
rhythm.  A  complete  reliance,  however,  on  the  respiratory  movements 
of  the  chest  and  abdomen  as  properly  indicating  the  patient's  condition 
in  anaesthesia  is  unwise  and  misleading,  for  these  movements  may  be  pres- 
ent after  complete  exclusion  of  air  from  obstruction  has  taken  place, 
which  may  be  caused  at  any  period  of  anaesthesia  by  foreign  bodies  in  the 
larynx  and  trachea,  such  as  false  teeth  and  vomited  matter.  In  complica- 
tions of  this  character  the  obstructing  agent  must  be  removed  immediately 
or  death  will  ensue,  unless  tracheotomy  be  performed.  During  vomiting 
the  head  should  be  so  lowered  and  turned  to  one  side,  as  to  carry  the 
vomited  matters  away  from  the  larynx ;  and  the  throat  and  mouth  should 
be  promptly  relieved  of  vomit  by  sponges.  The  rima  glottidis  may  be  ob- 
structed by  the  falling  backward  of  the  tongue,  which  happens  only  during 
the  stage  of  complete  anaesthesia,  and  can  be  readily  remedied  by  pressing 
the  jaw  forward  (Fig.  8),  or  by  seizing  the  tongue  with  the  forceps  or  a  dry 
cloth  and  pulling  it  forward  (Fig.  3).  A  tenaculum  may  be  used,  or  the 
finger  may  be  hooked  over  the  base  of  the  organ  and  the  tongue  pulled 
forward  by  this  means. 

Failure  of  respiration  not  dependent  on  obstructions  of  the  air-passages 
may  arise  from  senile  changes  of  the  respiratory  muscles  and  framework  of 
the  thorax,  chronic  intrathoracic  disease,  shock,  and  loss  of  blood. 

The  Dangers  of  Ancesthesia  and  their  Treatment. — The  successful  treat- 
ment for  the  relief  of  poisoning  due  to  an  overdose  of  an  anassthetic  will 
depend  not  only  upon  the  presence  of  mind  of  the  surgeon,  but  upon  the 
precautionary  preparations  which  have  been  made  for  such  a  contingency,  as 
well  as  the  promptness  and  judgment  with  which  the  remedies  are  applied. 

The  dangers  which  result  from  the  administration  of  anaesthetics  are 
connected  with  either  the  circulation  or  the  respiration.    The  dangers  from 


THE  GENERAL  CONSIDERATIONS.  17 

chloroform  are  chiefly  in  connection  with  the  circulation,  and  are  mani- 
fested by  various  degrees  of  circulatory  depression.  The  dangers  from 
ether  and  nitrous  oxide  are  chiefly  in  connection  with  the  respiration,  and 
are  manifested  by  various  degrees  of  asphyxia. 

The  various  degrees  of  asphyxia  attending  the  administration  of  anaes- 
thetics are  due,  for  the  most  part,  to  the  following  causes :  Direct  obstruc- 
tion to  respiration,  as  caused  by  a  valve-like  action  of  the  air  passages  and 
orifices  above  the  larynx,  and  by  foreign  bodies;  spasm  of  the  respiratory 
muscles  and  paralysis  of  the  respiratory  center  from  an  overdose. 

The  various  degrees  of  circulatory  depression  during  anaesthesia,  which 
are  attributable,  directly  or  indirectly,  to  the  anaesthetic,  are  due  to  giving 
too  little  or  too  much  of  the  agent.  The  giving  too  little  of  the  ansesthetic, 
causing  incomplete  ancesthesia,  may  result  in  depression  of  the  circulation 
from  nausea  and  reflex  effects  from  operative  procedures.  This  is  rare 
under  ether,  but  not  uncommon  under  chloroform.  Circulatory  depression 
from  an  overdose  of  the  ansesthetic  occurs  in  two  ways :  If  the  overdose  is 
administered  gradually,  the  dangerous  effects  upon  the  circulation  are 
usually  secondary  and  consecutive  to  dangerous  paralysis  of  respiration.  If 
the  overdose  is  administered  rapidly,  the  circulatory  depression  is  usually 
primary,  especially  in  the  case  of  chloroform.  Unduly  prolonged  narcosis 
often  causes  gradual  circulatory  depression.  The  immediate  dangers,  there- 
fore, in  the  administration  of  ana3sthetics  are  manifested  by  either  asphyxia 
or  syncope. 

One  of  the  greatest  sources  of  respiratory  obstruction  during  anaesthesia 
is  that  associated  with  stertor,  M^hich  may  be  of  nasal,  buccal,  palatine, 
pharyngeal,  or  laryngeal  origin.  Stertor  may  be  inspiratory  or  expiratory, 
and  may  occur  during  light  or  deep  ansesthesia.  During  light  ansesthesia  it 
is  frequently  reflex  from  operative  procedures,  while  during  deep  narcosis 
it  is  usually  paralytic.  The  direct  cause  of  stertor  is  the  interference  of  the 
tissues  and  organs  situated  in  the  air-way  above  the  trachea  with  the  cur- 
rents of  air  during  inspiration  and  expiration.  The  situation  of  the 
tongue,  its  weight,  and  its  relations  with  the  epiglottis  and  larynx,  render 
it  perhaps  the  greatest  source  of  obstruction  to  respiration  during  anaes- 
thesia. 

In  the  treatment  of  these  conditions  prophylaxis  is  of  the  greatest  value, 
for  a  majority  of  the  difficulties  and  dangers  of  anaesthesia  are  due  to 
faulty  administration. 

Reflex  stertor,  if  troublesome  and  distinctly  connected  with  the  opera- 
tive manipulations,  should  be  met  by  a  deeper  narcosis.  Stertor  not  result- 
ing from  too  light  narcosis  may  be  relieved  by  the  following  measures : 
extension  of  the  head  by  raising  the  chin  from  the  sternum;  pushing  the 
lower  jaw  forward  by  pressing  behind  its  angles ;  pulling  the  tongue  for- 
ward by  the  tip  or  hooking  it  forM^ard  from  its  base.  One  or  more  of  these 
measures  will  relieve  all  ordinary  obstructions  to  respiration  during  anaes- 
thesia; but  should  they  fail  and  the  asphyxia  be  alarming,  tracheotomy 
should  be  promptly  performed.  Obstruction  to  respiration  due  to  valve- 
like action  of  the  nares,  cheeks,  lips,  and  phar3mx,  should  be  prevented  or 
relieved  by  the  use  of  a  nasal  speculum  or  by  holding  the  mouth  open  with 


18  OPERATIVE  SURGERY. 

a  small  prop.  Obstruction  to  respiration  from  foreign  substances,  as 
blood,  mucus,  stomach  contents,  or  other  material,  should  be  met  by  their 
prompt  removal. 

An  exceedingly  rare  form  of  obstruction  to  respiration  during  anaes- 
thesia is  due  to  spasm  of  the  muscles  of  respiration  with  complete  cessation 
of  all  respiratory  movement.  This  form  of  obstruction  usually  occurs  in 
the  early  stages  of  narcosis  during  the  period  of  general  muscular  rigidity. 
All  that  can  be  done  in  such  cases  is,  to  see  that  the  air-way  is  free  and  then 
perform  vigorous  artificial  respiration.  All  forms  of  obstructed  breathing 
resulting  in  asphyxia,  with  cessation  or  practical  cessation  of  respiration, 
should,  after  determining  the  unobstructed  condition  of  the  air-way,  be 
treated  by  artificial  respiration.  During  this  time  the  administration  of 
oxygen  to  hasten  the  relief  from  asphyxia  is  indicated.  Asphyxia  from 
paralysis  of  respiration  from  an  overdose  of  an  angesthetic  is  treated  by 
stopping  the  administration,  and,  if  necessary,  promoting  elimination  of 
the  anaesthetic  by  artificial  respiration.  In  all  cases  of  asphyxia  the  heart 
should  be  sustained  by  the  administration  of  stimulants. 

The  best  methods  of  performing  artificial  respiration  for  the  purpose 
under  consideration  are:  simple  compressions  of  the  chest,  Silvester's 
method,  and  forced  respiration.  Forcible  compression  of  the  chest  and  its 
prompt  expansion  not  only  causes  a  considerable  movement  of  air  into  the 
lungs,  but  is  a  powerful  excitant  of  respiratory  effort,  when  the  patient's 
condition  renders  possible  such  response.  Air  forced  from  the  lungs  in  this 
way  also  serves  to  remove  obstructions,  such  as  undue  apposition  of  the 
epiglottis  to  the  laryngeal  opening,  foreign  bodies,  etc. 

Silvester's  method  of  artificial  respiration  is  readily  carried  out  and 
more  effective  than  other  similar  methods.  Faradism  of  the  phrenic 
nerves  is  a  decided  aid  to  artificial  respiration.  Forced  respiration  by 
means  of  the  Fell-0'Dwyer  or  similar  apparatus  would  probably  be  of  great 
value  in  extreme  cases  of  asphyxia  of  this  nature  if  the  apparatus  were  at 
hand  and  ready  for  use.      (See  Tumors  of  Ribs,  Vol.  II.) 

Tlte  syncope  which  occasionally  occurs  from  nausea  and  from  operative 
procedures  under  light  narcosis  by  chloroform  should  be  avoided  by  avoid- 
ing the  conditions  which  permit  it  to  occur. 

The  minor  degrees  of  circulatory  depression,  occurring  under  chloro- 
form, may  be  relieved  by  lessening  the  administration,  if  the  narcosis  is  of 
moderate  or  deep  degree,  or  by  changing  to  ether  or  A.  C.  E.  and  by  the 
administration  of  restorative  measures. 

Alarming  degrees  of  syncope  call  for  prompt  and  energetic  treatment. 
The  administration  should  be  stopped,  and  nothing  allowed  to  interfere  or 
delay  the  application  of  restorative  measures.  The  condition  of  the  circula- 
tion and  respiration  should  be  carefully  noted.  The  anaesthetic  contained 
in  the  air  of  the  patient's  lungs  should  be  removed  by  rapid  and  effective 
artificial  respiration,  and  throughout  the  treatment  of  the  case  the  air-way 
should  be  maintained  unobstructed.  In  the  treatment  of  the  graver  forms 
of  syncope  the  following  are  the  chief  measures  of  value : 

The  Posture. — More  or  less  inversion  of  the  patient  is  almost  invariably 
practised  under  these  circumstances,  and  there  can  be  no  doubt  that  many 


THE   GENERAL   CONSIDERATIONS.  19 

lives  have  been  saved  by  this  means.  The  improvement  in  the  pulsS  and 
respiration  following  inversion  in  approacliing  collapse  from  chloroform  is 
proof  of  its  value  under  these  circumstances.  Inversion  is  supposed  to  act 
by  determining  a  flow  of  blood  to  the  medulla  and  to  the  heart,  thus  stimu- 
lating respiration  and  circulation.  Inversion  has  been  employed,  however, 
in  nearly  all  of  the  fatal  chloroform  accidents.  Thus  it  is  evident  that  it 
is  not  invariably  effective;  indeed,  it  is  probable  that  it  is  often  positively 
harmful.  In  sudden  complete  syncope  the  heart  is  paralyzed  and  distended 
with  blood,  as  are  the  great  vessels  of  the  chest  and  abdomen.  Hill  has 
pointed  out  that  to  invert  a  patient  under  these  circumstances  is  "  worse 
than  useless,"  as  "  the  paralytic  dilatation  of  the  heart  is  thereby  increased." 
Hill  recommends  the  following  measures,  which  he  has  found  to  relieve 
nearly  every  case  of  this  kind  in  animals.  "  Artificial  respiration  is  at 
once  applied,  the  thorax  is  rhythmically  squeezed  over  the  region  of  the 
heart,  while  the  animal  is  placed  in  the  horizontal  position.  If  the  pulse 
does  not  speedily  return,  the  animal  is  dropped  into  the  vertical,  feet-down 
posture.  By  this  simple  means  the  heart,  owing  to  the  influence  of  gravity, 
is  emptied  into  the  splanchnic  area,  and  thus  the  dilatation  of  the  organ  is 
relieved.  Artificial  respiration  is  maintained  throughout  this  manoeuvre. 
After  a  few  seconds  the  animal  is  returned  to  the  horizontal  posture,  and 
the  heart  is  thus  filled  with  a  fresh  supply  of  blood.  If  the  pulse  does  not 
return,  the  movement  is  once  more  repeated.  When  the  pulse  has  returned 
and  the  heart  beat  has  become  efficient,  the  artificial  respiration  can  be  dis- 
continued, and  after  a  short  space  of  time  the  natural  breathing  will  usu- 
ally return,  owing  to  the  excitation  of  asphyxia.  During  this  period  the 
pulse  must  be  carefully  watched,  and  artificial  respiration  renewed  if  there 
be  any  signs  of  failure.  The  second  type  of  collapse  (slow  and.  gradual 
overdose)  is  relieved  by  the  vertical  head-down  position.  It  is  equally  re- 
lieved by  the  horizontal  position  and  artificial  respiration.  As  the  anges- 
thetist  can  never  be  sure  which  type  of  collapse  he  has  to  deal  with,  it  seems 
to  me  that  the  head-down  method  should  never  be  employed.  If  we  have  to 
deal  with  the  first  type  of  collapse  (sudden  overdose),  the  latter  method 
is  a  fatal  mistake;  if  the  second  tj'pe  of  collapse  confronts  us,  recovery  can 
be  brought  about  by  performing  artificial  respiration  and  placing  the  pa- 
tient in  the  horizontal  position." 

Artificial  respiration  carried  out  by  rhythmic  compressions  of  the 
thorax,  hy  Silvester's  method,  by  methods  of  forced  respiration,  and  by 
faradism  of  the  phrenic  nerves,  probably  affords  the  most  effective  means 
of  treating  syncope  from  anesthetics. 

The  method  by  heart  compression  has  proved  to  be  of  great  value  in 
many  cases  of  chloroform  s}Ticope.  "  The  operator  stands  on  the  left  side 
of  the  patient  with  face  toward  the  head  of  the  patient ;  the  cardiac  region 
is  pressed  upon  with  rapid  and  strong  pressure  by  the  ball  of  the  right 
thumb  laid  upon  the  chest  between  the  place  of  apex  beat  and  the  left  bor- 
der of  the  sternum ;  one  hundred  and  twenty  shocks  or  compressions  are  to 
be  made  per  minute.  Care  must  be  taken  to  exert  enough  force.  Fix  the 
patient's  body  by  the  left  hand  on  the  right  side  of  the  thorax.  Success 
is  denoted  bv  artificially  produced  carotid  pulse  and  contraction  of  pupils, 
4  " 


20  OPERATIVE  SURGERY. 

whicIT  should  control  the  force  and  rapidity  of  impulses.  An  assistant 
should  watch  the  pupil  and  carotid  pulse.  As  long  as  the  condition  of  the 
patient  does  not  improve,  the  pauses  in  treatment  should  be  as  far  between 
and  as  short  as  possible.  When  the  pupil  contracts  you  may  wait  till  it 
begins  to  dilate,  or  as  long  as  spontaneous  respiratory  movements  con- 
tinue."    (Maas.) 

The  Drugs. — Experiments  have  demonstrated  the  great  value  of  strych- 
nin and  digitalis  in  the  treatment  of  syncope  from  chloroform,  and  the 
inefficiency  of  alcohol,  atropin,  ammonia,  amyl  nitrite,  and  caffein. 
Strychnin  must  be  used  in  large  doses  under  these  circumstances.  The 
author  (Dr.  Bennett)  has  given  three-twentieths  of  a  grain  in  divided  doses 
with  advantage  upon  several  occasions,  and  others  have  given  still  more. 

Also  experiments  prove  that  suprarenal  extract  acts  as  a  powerful  vaso- 
motor stimulant,  and  is  highly  recommended  as  an  antidote  to  the  de- 
pressant effect  of  chloroform. 

The  striking  effects  of  the  rectal,  the  subcutaneous,  and  the  intravenous 
injection  of  saline  solutions  in  conditions  of  shock  and  of  collapse  is  proof 
of  their  value  in  syncope  from  anaesthetics.  Laborde's  method  (page  22) 
of  "  tongue  traction "  has  been  resorted  to  in  many  cases  of  apparent 
death  from  anesthetics  with  excellent  results. 

Brisk  rubbing  of  the  lips  often  excites  increased  respiratory  efforts, 
and  in  the  light  breathing  which  occurs  early  in  an  overdose  this  excitant 
may  be  used  to  advantage.  Faradism  of  the  heart  and  its  puncture  with  a 
needle  have  been  recommicnded  in  chloroform  syncope,  but  are  imprac- 
ticable and  of  doubtful  value. 

The  After-Effects. — Nausea  and  vomiting  constitute  the  most  conspic- 
uous and  distressing  though  not  the  most  dangerous  consequences  of  anaes- 
thesia. Nitrous  oxide  causes  the  least  after-disturbance  of  this  kind. 
Ether  causes  nausea  and  vomiting  more  frequently  than  chloroform,  but 
more  cases  of  protracted  and  dangerous  vomiting  are  met  with  after  chloro- 
form than  after  ether. 

Patients  differ  greatly  in  this  respect.  A  patient  may  vomit  excessively 
on  one  occasion,  and  little  or  none  on  another,  under  apparently  like  con- 
ditions. Patients  properly  prepared  for  anaesthesia  have  less  sickness  than 
those  unprepared,  although  in  many  instances  cases  with  full  stomachs  and 
no  preparation  are  not  nauseated  from  anaesthesia.  Washing  out  the  stom- 
ach at  the  close  of  the  administration  will  lessen  and  perhaps  prevent  nau- 
sea and  vomiting  in  a  large  percentage  of  cases,  and  is  an  excellent  routine 
practise  which  should  be  carefully  done. 

At  later  periods  this  is  one  of  the  best  means  of  treatment.  After  con- 
sciousness has  been  restored  it  may  be  practised  at  proper  intervals  by  caus- 
ing the  patient  to  drink  a  glass  of  warm  water  and  expel  it  by  vomiting. 
A  large  dose  of  the  bromide  of  sodium  or  potassium  by  rectum  will  often 
act  beneficially.  The  administration  of  opium  is  occasionally  the  only 
means  that  will  control  this  infliction. 

Headache  following  anaesthetics,  commonly  noted  after  prolonged  ad- 
ministration of  nitrous  oxide,  is  best  relieved  by  cold  applications  to  the 
head,  by  bromide,  or  opiates. 


THE  GENERAL  CONSIDERATIONS.  21 

Bronchitis,  hroncho-pneumonia,  and  typical  lobar  pneumonia  have  oc- 
curred with  noticeable  frequency  soon  after  anaesthesia.  These  diseases 
occur  after  all  anaesthetics,  but  more  commonly  after  ether  than  chloroform. 
They  are  not  due  to  the  direct  effect  of  the  anassthetics  on  the  pulmonary 
tissues,  but  are  caused,  for  the  most  part,  by  infection  of  the  lungs  arising 
from  aspirated  infected  material  released  from  the  throat  during  the  nar- 
cosis. Add  to  this  the  chilling  influences  attending  the  ancesthesia  and  the 
operation,  the  repression  of  coughing  after  certain  operations,  and  the 
exposure  incident  to  change  from  the  operating  room,  change  of  clothing, 
etc.,  and  it  is  not  surprising  that  these  pulmonary  after-effects  occasionally 
develop. 

Prophylaxis  consists  chiefly  in  the  use  of  clean  inhalers,  cleansing  the 
mouth,  nose,  and  throat  before  administration,  avoiding  aspiration  of  for- 
eign material  into  the  air  passages,  and  keeping  the  patient  free  from  ex- 
posure and  depression. 

Renal  congestion,  nephritis,  and  urinary  suppression  are  not  infre- 
quently observed  after  the  administration  of  an  anaesthetic.  The  effects  of 
the  deprivation  of  fluids  before  and  after  operation,  the  exposure  attending 
it,  and  sepsis  must  not  be  overlooked  in  this  connection.  Saline  infusion 
by  way  of  the  rectum,  cellular  tissue,  or  veins  has  proved  of  great  benefit 
in  promoting  kidney  action  under  these  conditions. 

Jaundice,  glycosuria,  insanity,  and  other  abnormal  states  have  been 
noted  after  anaesthesia.  Their  exact  relations  to  the  narcosis  are  not  fully 
understood. 

The  After-Care. — During  the  recovery  of  patients  from  the  effects  of 
antesthetics  they  should  have  certain  special  care.  They  should  receive 
assistance  during  the  vomiting,  and,  owing  to  the  suddenness  of  its  occur- 
rence, the  patient  should  not  be  alone  until  capable  of  taking  care  of  him- 
self. Vomiting  is  easily  and  safely  accomplished  if  the  patient  is  lying  on 
the  side.  If  the  dorsal  position  is  necessary,  the  head  should  be  turned 
well  to  one  side  during  vomiting.  The  elevation  of  the  corresponding  shoul- 
der will  aid  the  act.  Vomited  matters  should  be  removed  from  the  mouth 
as  quickly  as  possible.  The  common  custom  of  pushing  the  jaw  forward 
during  vomiting  is  unnecessary  and  dangerous.  The  act  draws  the  tongue 
forward,  exposing  the  glottis,  thus  defeating  the  natural  means  of  pro- 
tecting the  air  passage. 

The  patient  should  be  guarded  from  exposure  during  recovery.  The 
chilling  influences  of  the  anaesthetic  and  the  operation  render  the  patient 
unusually  sensitive,  and  more  than  usual  covering  should  be  provided. 
Artificial  heat,  when  necessary,  should  be  provided,  but  the  application 
should  be  cautiously  made,  as  the  patient,  being  more  or  less  anaesthetic, 
may  not  appreciate  that  he  is  being  burned.  The  patient  should  not  be 
exposed  to  draughts,  and  undue  sweating  should  be  remedied. 

The  question  of  food  and  drinh  is  important.  The  custom  of  with- 
holding everything  for  many  hours  is  unnecessary.  The  patient's  de- 
sire for  food  and  drink  is  often  a  reliable  guide  for  the  giving  in  small 
amount.  Weak  patients  should  not  be  kept  as  long  as  the  strong  with- 
out nourishment.     As  a  rule,  it  is  best  to  begin  with  small  quantities 


22  OPERATIVE  SURGERY. 

of  warm  fluids,  continuing  according  to  the  conditions  that  present.  Thirst 
may  be  relieved  by  giving  large  amounts  of  fluid  by  the  rectum  and  small 
amounts  by  the  mouth. 

The  Lahorde  Method  of  Artificial  Respiration. — Laborde,  who  claims 
that  traction  made  on  the  tongue  excites  directly  the  contractile  respiratory 
function  of  the  diaphragm,  recommends  the  following  method  of  artificial 
respiration :  Place  the  patient  on  the  back  with  the  head  low,  clothing 
loosened,  and  jaws  held  apart.  Free  the  throat  from  mucus;  seize  the 
tongue  far  back  between  the  thumb  and  index  finger,  already  covered  with  a 
dry  cloth  to  prevent  slipping;  pu.ll  the  entire  tongue  sharply  forward,  once 
in  four  seconds — fifteen  times  per  minute — allowing  prompt  relaxation. 
These  movements  should  be  kept  up  for  half  an  hour  or  more,  as  may  seem 
necessary.  The  Laborde  method  can  be  supplemented  by  concentric  tho- 
racic and  upward  abdominal  pressure  applied  in  a  rhythmic  manner  by  two 
assistants  at  the  time  of  relaxation  of  the  tongue.  While  it  is  difficult  now 
to  estimate  the  relative  worth  of  this  method,  there  seems  good  reason  to 
regard  it  with  favor,  especially  when  practiced  in  connection,  as  already 
indicated,  with  other  manipulations. 

The  Results: 

Statistics  collected  by  Julliard :       administrations,  deaths.  Eatb. 

Chloroform  . 524,507         161  1  in     3,358 

Ether 314,738  21  1  in  14,987 

Statistics  collected  by  Ormsby : 

Chloroform 152,260  53         1  in     2,873 

Ether 92,815  4         1  in  23,204 

Statistics  collected  by  Gurlt  in  Ger- 
many from  1891  to  1897: 

Chloroform 1  in     2,039 

Ether 1  in     5,000 

Statistics  from  St.  Bartholomew's 
Hospital  from  1875  to  1890 : 

Chloroform 19,526  13         1  in     1,502 

Ether  8,491  3    •     1  in     2,830 

"  Gas  and  ether "   12,941  1         1  in  12,941 

There  are  only  very  few  deaths  reported  from  nitrous  oxide,  consider- 
ing the  millions  of  administrations  that  have  taken  place ;  the  7'ate  of  mor- 
tality is  probably  one  in  several  hundred  thousand. 

It  is  our  opinion  that  the  statistics  of  ansesthesia  are  particularly  unre- 
liable and  misleading  owing  to  the  unreported  fatalities,  of  which  there  are 
probably  a  far  greater  number  than  those  reported. 

Another  source  of  error  is  the  fact  that  the  fatalities  reported  are,  for 
the  most  part,  due  to  the  im,mediate  effect  of  the  anaesthetic,  while  those 
dying  subsequently  from  conditions  which  may  be  attributed  partly  or 
wholly  to  the  anaesthetic  are  more  apt  to  go  unrecorded.  Ether  probably 
furnishes  a  greater  number  of  these  latter  cases  than  chloroform,  conse- 


THE  GENERAL  CONSIDERATIONS.  23 

quently  the  statistics  of  chloroform  are  probably  more  favorable  than  are 
generally  believed.  Nitrous  oxide  is  the  safest  general  anaesthetic,  if  its 
use  is  restricted  to  comparatively  brief  administrations.  However,  the 
prolonged  administration  of  this  angesthetic  is  quite  a  different  matter. 
At  the  present  time  there  are  not  sufficient  data  relating  to  this  plan  of 
use  to  warrant  reliable  conclusions  as  to  its  safety.  The  writer  has  admin- 
istered gas  with  air  or  with  oxygen  for  operations  lasting  a  few  minutes 
and  two  hours  or  more  in  several  hundred  cases,  without  fatal  out- 
come, although  alarming  symptoms  have  several  times  occurred  with  such 
rapidity  and  with  so  little  warning  that  it  seems  probable  that  the  general 
adoption  of  this  variety  of  anesthesia  would  lead  to  a  mortality  quite  ap- 
proximating, if  not  exceeding,  that  of  chloroform  and  ether. 

Ether  is  undoubtedly  second  in  safety,  whether  used  alone  or  following 
nitrous  oxide. 

Chloroform  is  the  least  safe  of  the  agents  under  consideration. 

In  mixtures  such  as  A.  C.  E.  the  most  active  ingredient  is  chloroform, 
the  effect  of  which  is  modified  by  dilution  and  by  the  action  of  the  other 
elements  of  the  mixture.  In  point  of  safety  these  mixtures  should  prob- 
ably be  placed  between  those  of  ether  and  chloroform ;  the  greater  the  pro- 
portion of  chloroform  the  more  dangerous  is  the  mixture. 

From  the  standpoint  of  statistics,  the  choice  of  an  angesthetic  should  be 
as  follows : 

First,  nitrous  oxide  for  such  operations  as  necessitate  no  more  than  one 
complete  administration  of  the  gas. 

Second,  ether,  whether  given  alone  or  preceded  by  nitrous  oxide. 

Third,  a  mixture  such  as  A.  C.  E. 

Fourth,  chloroform. 

There  are,  however,  other  factors  than  statistics  to  be  considered  before 
a  proper  choice  can  be  made,  and  these  are  found  in  connection  with  the 
condition  of  the  patient  and  the  nature  of  the  operation. 

Ether. — Ether  is  employed  much  more  in  surgery  in  this  country  than 
all  the  other  angesthetics  combined.  The  chief  objections  to  its  use  are  its 
pungency  and  inflammability,  and  the  causation  of  nausea,  vomiting,  and 
cerebral  excitement.  The  pungency  can  be  lessened,  and,  in  fact,  almost 
entirely  obviated,  if  a  good  volume  of  air  be  caused  to  mingle  with  it  during 
the  first  few  moments  of  administration.  One  has  but  to  cover  one's  own 
face  with  the  well-charged  ether  cone  in  common  use  to  appreciate  the  sense 
of  impending  suffocation  that  is  experienced  by  the  patient,  whose  resistance 
is  often  violent,  and  suggestive  of  the  belief  that  on  his  part  the  struggle  is 
for  life.  Scenes  of  this  kind  ought  always  to  be  avoided.  The  resultant 
nausea  and  vomiting  are  not  of  sufficient  importance  to  contra-indicate  the 
use  of  ether,  except  in  such  cases  as  would  be  unfavorably  affected  by  these 
manifestations.  Vomiting  is  more  dangerous  when  solid  food  has  been  re- 
cently taken,  as  then  it  may  enter  the  larynx  and  trachea  and  cause  suffo- 
cation. In  not  all  instances  does  vomiting  occur  even  when  the  stomach  is 
more  or  less  replete  with  food.  This  fact,  however,  should  not  prompt  the 
giving  with  thoughtless  haste. 


24  OPERATIVE   SURGERY. 

The  In-flammaMlity. — This  characteristic  is  to  be  regarded  only  while 
operating  in  the  presence  of  artificial  light  and  with  the  use  of  actual  cau- 
tery. The  employment  of  actual  cautery  in  or  near  the  mouth  of  a  patient 
while  under  the  influence  of  ether  is  to  be  avoided,  for  obvious  reasons ;  in 
cases  like  this  ether  should  not  be  employed,  except  with  extraordinary  care, 
and  then  only  when  absolutely  necessary.  The  liability  of  ignition  in  the 
presence  of  artificial  light  is  lessened  by  the  fact  that  the  weight  of  the  vapor 
creates  a  downward  current,  thereby  tending  to  remove  it  from  contact  with 
an  igniting  agent  placed  at  the  usual  distance  above  the  patient.  It  is  wiser, 
however,  for  all  concerned  to  treat  ether  on  such  occasions  as  if  it  were  wait- 
ing only  for  the  slightest  opportunity  to  assert  its  explosive  power. 

The  cerebral  excitement  which  often  precedes  complete  anaesthesia  may 
depend  entirely  on  the  drug  or  be  provoked  by  surrounding  circumstances. 
The  patient  should  be  assured  that  no  harm  will  attend  the  administration, 
and  it  should  be  given  in  a  gentle  manner — slowly  at  the  beginning — in  order 
that  the  bronchial  mucous  membrane  may  not  suffer  too  great  irritation. 

Ether  is  employed  more  often,  perhaps,  than  is  wise  if  the  various  con- 
ditions of  those  to  whom  it  is  administered  were  analyzed  and  the  resulting 
conclusions  were  met  by  the  adoption  of  the  anaBSthetic  best  calculated  to 
meet  the  exact  requirements  of  a  case.  The  quite  pronounced  general  aver- 
sion to  the  use  of  chloroform,  the  inability  to  command  nitrous  oxide,  and 
the  inexperience  with  A.  C.  E.  mixture,  all  hinder  a  proper  discrimination 
in  the  general  employment  of  ether.  When  practicable  to  avoid  it,  ether 
should  not  be  administered  to  the  aged,  especially  if  marked  atheromatous 
changes  are  noticeable.  Acute  or  chronic  kidney  and  pulmonary  disease, 
or  any  intrathoracic  affection  attended  with  dyspnoea  or  cyanosis,  contra- 
indicates  the  use  at  all  ages.  In  laryngeal  stenosis  from  any  cause  the  spasm 
of  the  respiratory  forces  excited  by  the  use  of  ether  often  produces  alarm- 
ing symptoms,  and  even  death,  dependent  on  suffocation.  Ether  is  not  as 
well  borne  by  the  obese  and  plethoric  as  by  the  stout  and  relaxed,  provided 
the  latter  be  not  full-blooded.  There  is  reason  to  believe  that  ether  is  not 
well  borne  by  those  who  have  been  long  addicted  to  the  excessive  use  of 
alcoholics,  irrespective  of  the  influence  on  the  patient  of  the  visceral  lesions 
that  so  often  take  place  as  the  result  of  their  use. 

Ether  Inhalers. — The  variety  of  inhalers  for  the  administration  of  ether 
is  so  great  that  it  is  no  part  of  my  intention  to  discuss  their  comparative 
worth,  but,  instead,  to  speak  only  of  those  in  common  use,  and  at  the  same 
time  to  offer  to  one  who  is  removed  from  the  basis  of  surgical  supplies  a 
knowledge  that  will  enable  him  to  construct  the  kind  of  cone  that  is  largely 
employed.  The  simplest  method  of  administering  ether  is  by  moistening  a 
napkin  or  towel  with  the  fluid  and  holding  it  to  the  nose  and  mouth.  This 
plan  is  not  satisfactory,  inasmuch  as  it  involves  an  unwise  expenditure  of 
time,  a  great  waste  of  ether,  and  produces  less  satisfactory  anaesthesia  than 
any  other  method.  In  fact,  this  plan  is  employed  so  rarely  as  not  to  be 
esteemed  of  any  special  significance. 

The  simplest  form  of  inhaler  is  known  as  the  "  cloth  and  paper  cone  " 
(Fig.  9). 


THE  GENERAL  CONSIDERATIONS.  25 

The  construction  of  this  inhaler  is  simple,  and  the  materials  employed 
are  always  accessible.     A  sheet  of  paper  of  strong  texture,  or  three  or  four 
layers  of  an  ordinary  newspaper  two  feet  in  length  and  eighteen  or  twenty 
inches  in  width,  together  with  a  strong  piece  of  cloth  the  dimensions  of 
which  exceed  those  of  tl:^  paper  by  two  or  three  inches,  and  a  dozen  ordi- 
nary pins,  are  all  that  is  required.     Place  the  cloth — a  towel  is  usually  em- 
ployed— and  the  paper  on  a  table,  with  the  paper  uppermost ;  fold  them  in 
the  middle  of  their  long  diameter  so  as  to  bring 
.        the  cloth  on  the  outer  surface  and  the  paper  within. 
I        Then  fold  them  in  the  short  diameter,  the  length 
I       of  the  fold  corresponding  to  the  distance  from  the 
1       symphysis  mentis  to  the  root  of  the  nose  of  the 
\      patient ;  when  thus  folded,  wrap  around  the  fold 
1      the  remainder  of  the  material,  and  pin  the  outer 
^i      and  inner   extremities   firmly  through   the   whole 
zJ     texture  of  the  sides,  using  care  that  the  pins  be  so 
Fig.  9.— Cloth  and  paper     placed  as  not  to  stick  the  patient's   face  or   the 
cone.  hands  of  the  administrator.     Several  pins  are  passed 

through  all  the  textures  in  various  situations  to 
hold  them  firmly  together.  One  end  can  be  closed,  which  is  easily  and 
quickly  accomplished  by  turning  inward  the  borders  and  securely  pinning 
them  to  each  other.  It  is  better  to  close  the  end  formed  by  the  free  borders 
of  the  material,  reserving  the  other  as  a  firmer  basis  to  the  cone.  Into  the 
top  of  the  cone  is  crowded  a  good-sized  sponge  or  a  piece  of  coarse-textured 
cloth,  always  observing  that  it  is  well  above  the  face  of  the  patient.  Numer- 
ous layers  of  muslin  may  be  interposed  between  the  borders  of  the  upper  end, 
instead  of  closing  it  by  turning  and  pinning  as  just  described.  If  this  mate- 
rial be  confined  in  position  by  means  of  pins,  and  the  end  covered  with  a 
layer  of  thin  gauze,  the  ether  can  then  be  poured  upon  it  and  thus  be  admin- 
istered without  removing  the  cone  from  the  face.  The  advantages  which 
this  simple  inhaler  possesses  over  the  permanent  and  more  expensive  ones 
are  quite  numerous.  It  can  not  be  damaged  by  the  patient,  nor  will  the 
face  be  bruised  by  its  borders  during  his  struggles ;  it  is  a  temporary  affair, 
and  therefore  need  never  be  used  a  second  time — a  fact  which  is  obviously 
of  considerable  importance  in  a  fastidious  and  hygienic  sense.  It  does  not, 
however,  admit  of  the  easy  regulation  of  the  amount  of  ether  to  be  given, 
nor  the  amount  of  air  to  be  admitted ;  it  is  also  liable,  unless  care  be  used  in 
replenishing  it  with  ether,  to  permit  the  anesthetic  to  fiow  into  the  eyes  and 
upon  the  face  of  the  patient;  in  addition,  the  air  space  is  almost  invariably 
contracted  during  the  struggles  of  the  patient ;  yet  these  are  objections 
which  can  be  easily  surmounted  by  a  requisite  degree  of  caution.  The 
amount  of  ether  required  with  this  apparatus  is  less  than  if  a  napkin  be 
used  alone,  but  it  exceeds  that  employed  in  the  more  perfect  inhalers. 

Allis^  Inhaler. — Allis'  inhaler  is  made  of  a  fenestrated  metallic  framework 
for  the  support  of  cloth  partitions  (Fig.  10),  surrounded  by  an  adjustable 
leather  or  rubber  covering  (Fig.  11).  It  is  simple,  efficient,  portable,  and  can 
be  quite  easily  cleansed.     Briefly  stated,  its  advantages  are  the  following :  It 


26 


OPERATIVE  SURGERY. 


allows  a  free  admission  of  air  from  above,  which  becomes  saturated  with 
ether;  the  evaporating  surface  is  great,  causing  thereby  a  rapid  vaporization, 
which  hastens  anaesthesia  and  saves  ether ;  the  ether  can  be  replenished 
through  the  top,  which  obviates  the  necessity  of  removing  the  inhaler  and 
interrupting  the  administration.  The 
cloth  partitions  can  be  readily  changed 


Figs.  10,  11.— Allis'  inhaler. 

whenever  propriety  and  cleanliness  demand.  Fowler  has  modified  this  in- 
haler by  making  it  collapsable,  thereby  economizing  space  in  a  surgical  outfit 
(Fig.  13). 

The  inhalers  of  Clover,  Squibb,  Ormsby,  and  others  are  all  serviceable, 
and  whoever  possesses  either  of  them  can,  so  far  as  the  apparatus  is  con- 
cerned, administer  ether  with  safety.  It  is  not  necessary  to  the  security  of 
the  patient  that  any  special  one  le  employed.     It  is,  however,  necessary,  no 


i„..is^r 

.„S!.^^i„.  4: 

'smm 

:              1 

R:^!^;:;-- 

n\  |v.i       Ey^i- 

'ji^^^i 

Fig.  12. — Fowler's  modification  of  Allis'  inhaler  (collapsable). 

matter  which  one  be  used,  that  the  administrator  of  the  anaesthetic  shall  rely 
on  the  knowledge  of  the  principles  governing  the  administration  rather  than 
on  the  apparatus  used. 

Clover'' s  Inhaler  (Fig.  13).— Clover's  inhaler  consists  of  a  receptacle  hold- 
ing two  ounces  of  ether,  a  mouthpiece  cushioned  with  inflated  rubber  fitting 
closely  over  the  patient's  nose  and  mouth,  and  connected  with  the  ether  re- 
ceptacle in  such  a  manner  that  the  amount  of  ether  inhaled  may  be  increased 
or  diminished  at  will.  The  rubber  bag  which  receives  the  expired  air  is 
charged  with  ether  vapor  at  the  same  time. 

The  advantages  claimed  for  this  inhaler  are :  The  patient  can  be  anaes- 
thetized in  a  very  short  time ;  the  depression  of  the  system  is  not  so  great ; 
the  patient  recovers  consciousness  more  quickly,  and  does  not  feel  the  effects 
of  ether  as  long  as  with  the  use  of  simpler  forms  of  ether  inhalers.     The 


THE  GENERAL  CONSIDERATIONS. 


27 


amount  of  ether  inhaled  is  regulated  by  adjustment  of  the  apparatus;  when 
turned  at  0,  no  ether  is  inhaled;  when  at  1,  one  quarter  is  ether  vapor;  at  2, 
one  half ;  at  3,  three  quarters ;  and  at  F  the  entire  amount  inhaled  is  ether 
vapor.  Thus  the  quantit}'  of  ether  administered  can  be  increased  or  di- 
minished during  the 


operation.  The  small 
amount  of  ether  con- 
sumed renders  this 
inhaler  very  econom- 
ical for  hospital  and 
field  service. 

Onnshi/s  Inhaler 
(Fig.  14).  —  Orms- 
by's  inhaler  is  the  simplest  device  for  giving 
ether  by  the  close  method.  It  is  not  a  regulat- 
ing inhaler,  such  as  Clover's,  and  is,  therefore, 
inferior  to  the  latter  for  the  induction  of  nar- 
cosis, but  is  considered  preferable  for  continuing 
the  administration,  being  smaller,  and  having  an 
air  tap  for  regulating  the  air  supply. 

The  amount  of  ether  required  to  produce  in- 
sensibility depends  upon  several  conditions,  the 
most     important     of 


Fig.  13. — Clover's  inhaler. 


which  are  the  suscep- 
tibility of  the  patient,  the  manner  of  adminis- 
tering, and  the  purity  of  the  anesthetic.  Some 
persons  can  be  completely  anaesthetized  by  an 
ounce,  and  even  less;  on  the  other  hand,  one 
occasionally  meets  with  those  who  "  take  ether 
badly,"  and  can  not  be  rendered  quiet  unless 
an  unusual  amount  be  given;  rarely,  indeed, 
a  case  is  encountered  wliich  apparently  will 
not  yield  to  its  influence,  and  the  surgeon  is 
forced  to  desist  in  the  interest  of  the  patient's 
safety.  It  is  not  prudent  to  predicate  in  ad- 
vance the  definite  amount  of  ether  that  will 
be  required,  except  possibly  in  some  peculiar 
cases.  AuEesthesia  is  never  to  be  attempted  un- 
less the  surgeon  is  certain  he  has  a  sufficient 
quantity  of  the  anaesthetic  to  complete  the 
operation,  for  nothing  can  be  more  humiliat- 
ing than  to  be  obliged  to  discontinue  an  oper- 
ation for  the  purpose  of  procuring  an  addi- 
tional amount.  It  is  not  wise  to  begin  an  operation  that  requires  much 
time  and  care  unless  at  least  one  pound  of  ether  be  at  hand. 

The  Manner  of  administering  Ether. — The  manner  of  administering 
ether  will  depend  somewhat  upon  the  kind  of  inhaler  that  is  used ;  if  it  be  of 


Fig.  14. — The  Ormsby  ether 
inhaler.  A,  face-piece  with 
inflatable  rubber  edge  (de- 
tachable). B,  tap  for  ad- 
mission of  air  and  addition 
of  ether,  which  passes  to  the 
cage  D  through  the  tube  C. 
E^  the  rubber  bag  which 
permits  re-breathing. 


28 


OPERATIVE  SURGERY. 


simple  construction  (Fig.  9),  one  should  begin  by  pouring  a  small  amount 
(an  ounce  or  so)  into  or  upon  the  inhaler  (Figs.  10  and  11),  and  adjusting 
the  apparatus  so  that  a  good  volume  of  air  will  mingle  with  the  ether  for 
the  first  few  moments  of  the  administration.  After  the  sense  of  pungency 
has  somewhat  subsided,  the  patient  should  be  told  to  "  cough,"  "  breathe 
deeply,"  at  the  same  time  the  fresh  air  is  quite  rapidly  excluded  from  the 
lower  end  of  the  cone.  The  patient  soon  becomes  oblivious,  and  may  be 
fully  anassthetized  without  further  delay.  Often,  however,  the  patient  will 
be  seen  to  pass  through  three  distinct  stages  of  anaesthesia,  which  will  vary 
in  their  length  and  manifestations  according  to  individual  circumstances. 
In  ether,  as  a  rule,  the  pupils  are  dilated  and  in  direct  proportion  to  the 
depth  of  the  anaesthesia. 

Bennett's  Ether  Inhaler   (Fig.   15). — Bennett's  inhaler  combines  the 
advantages  of  Clover's  and  Ormsby's  inhalers  in  that  the  strength  of  the 
ether  vapor  and  the  supply  of  air 
are  under  perfect  control. 

Chloroform. — Chloroform  is  a 
colorless  liquid,  having  an  agree- 
able odor  and  a  sweet  taste;  is  of 
high  specific  gravity,  and  non-in- 
flammable. Were  it  not  for  the 
inherent  dangers  attending  the 
administration  it  would  without 
doubt  be  the  most  satisfactory 
anaesthetic  in  use.  Ordinarily  the 
patient  passes  under  its  influence 
without  the  exhibitions  of  turbu- 
lence and  bronchial  irritation  that 
distinguish  ether. 

There  are  not  many  practical  differences  between  the  manifestations  of 
normal  chloroform  anaesthesia  and  those  of  ether.  In  ether  anaesthesia, 
stertorous  breathing  and  the  abolition  of  the  reflexes  do  not  contra-indicate 
a  continuous  administration  of  the  drug.  In  chloroform  anaesthesia,  how- 
ever, the  presence  of  those  expressions  are  suggestive  of  the  necessity  for 
additional  caution  in  the  administration,  since  alarming  symptoms  may 
rapidly  supervene  at  this  time  if  fresh  air  be  excluded  or  the  amount  admin- 
istered be  increased. 

The  fatalities  from  the  use  of  chloroform  are  largely  dependent  on  the 
inadequate  dilution  of  the  vapor  with  fresh  air  during  the  time  of  adminis- 
tration. If  this  fact  be  kept  clearly  in  view  under  all  circumstances,  and 
the  indications  be  observed,  the  danger  from  chloroform  is  not  of  sufficient 
moment  to  forbid  its  use  when  other  anaesthetics  are  especially  objectionable. 
The  stage  of  excitement  and  the  period  immediately  following  it  are  the 
times  of  greatest  danger ;  as,  during  the  former  period,  the  deep  inspirations 
of  the  patient,  supplemented  by  a  close  or  thoughtless  application  of  the  in- 
haler, cause  too  great  a  volume  of  improperly  aerated  chloroform  vapor  to 
be  inhaled.    "  With  ether  it  is  possible,  almost  with  impunity,  to  pass  be- 


FiG.  15. — Bennett's  ether  inhaler. 


THE  GENERAL  CONSIDERATIONS.  29 

yond  the  realm  of  reflex  action,  and  to  keep  up  an  unnecessarily  deep  nar- 
cosis; but  with  chloroform  this  is  not  the  case,  an  overdose  being  likely, 
with  but  little  warning,  to  set  up  the  most  alarming  symptoms"  (Hewitt). 

It  is  now  quite  generally  believed  that  chloroform  destroys  by  paralyzing 
the  respiratory  centers  (Hyderabad  Commission).  Wood  and  others,  how- 
ever, dissent  from  this  view,  and  Wood  presents  a  record  of  384  deaths  dur- 
ing chloroform  ancesthesia,  in  which  the  pulse  failed  entirely  before  respira- 
tion in  227  cases,  the  respiration  and  pulse  simultaneously  in  77,  and  the 
respiration  first  in  80  cases.  The  anaesthetist  should  watch  closely  for  any 
unusual  respiratory  and  cardiac  manifestations  during  the  time  of  chloro- 
form anaesthesia,  and  if  any  such  occur,  the  administration  should  be  sus- 
pended and  prompt  measures  of  relief  be  taken. 

The  fact  that  respiratory  paralysis  is  said  to  distinguish  chloroform  poi- 
soning ought  not  to  foster  inattention  to  cardiac  action  as  indicated  by 
radial  pulsation.  On  the  contrar}^,  the  anaesthetist  should  realize  that 
feeble,  hesitating,  and  irregular  cardiac  action  without,  or  perhaps  with  but 
trifling  respiratory  failure  during  chloroform  narcosis,  is  often  a  matter  of 
grave  significance.  Usually  the  pupils  are  moderately  contracted  in  chloro- 
form ansesthesia. 

Other  things  being  equal,  the  cases  best  suited  for  chloroform  narcosis 
are: 

1.  Those  requiring  operations  on  the  throat  and  mouth,  especially  if 
actual  cautery  is  to  be  employed.  It  is  not  an  infrequent  practice  in  these 
cases  to  give  ether  to  a  complete  anaesthesia,  and  then  continue  with  chloro- 
form. In  fact,  ether  must  not  be  employed  continuously  here  if  actual 
cautery  is  contemplated,  as  unfortunate  accidents  have  arisen  from  the  un- 
avoidable combustion  of  ether  vapor.  However,  it  should  be  recalled  that 
the  decomposition  of  chloroform  vapor  into  phosgene  gas  by  aid  of  gaslight 
often  causes  bronchial  irritation  and  coughing  of  the  attendants,  and  it  is 
reported  to  have  caused  death  of  the  patient  from  pneumonia  in  one  instance. 

2.  Operations  on  the  neck  complicated  with  present  or  prospective  venous 
engorgement,  as  in  tracheotomy  for  the  relief  of  laryngeal  stenosis,  etc. 

3.  In  abdominal  section,  to  avoid,  if  possible,  the  unpleasant  results  fol- 
lowing the  coughing,  vomiting,  and  struggling  of  the  patient,  which  are 
common  with  the  use  of  ether. 

4.  In  operations  directed  to  the  anus,  perinseum,  and  genital  organs,  the 
potent  analgesic  effects  of  chloroform  are  often  serviceable,  especially  if 
there  be  objection  to  the  profound  anaesthesia  of  ether,  which  is  often  neces- 
sary to  overcome  the  acute  sensibility  of  these  parts  of  the  body.  For  the 
same  reason  chloroform  offers  special  advantages  in  oral  and  ocular  surgery, 
and  in  labor.  However,  the  greater  the  dose  of  chloroform  the  greater  is 
the  danger. 

5.  Chloroform  can  be  employed  wisely  in  childhood,  and  in  the  ather- 
omatous changes  of  old  age.  However  children  are  not  specially  immune 
to  danger  from  this  drug. 

The  Administration. — Before  the  administration  of  chloroform  is  begun, 
the  nose  and  adjacent  portions  of  the  face  should  be  smeared  lightly  with 


30 


OPEE.A.TIVE  SURGERY. 


vaseline  or  a  similar  substance,  to  obviate  the  danger  of  the  vesication  that 
frequently  arises  from  the  incautious  contact  of  the  drug  with  the  naked  skin. 
Chloroform  may  be  administered  by  the  aid  of  a  plain  smooth  napkin  held 
near  to  the  nose  and  mouth  of  the  patient.  Not  infrequently  the  napkin  is 
rumpled  into  a  conelike  form  and  used  in  that  shape.  In  either  instance  the 
chloroform  should  be  dropped  on  the  cloth  rather  than  poured  on,  as  then  a 
suitable  amount  can  be  easily  estimated.  Four  or  five  drops  used  at  the  out- 
set is  quickly  followed  by  a  similar  or  even  larger  quantity.  This  amount 
repeated  from  time  to  time,  supplemented  by  a  liberal  supply  of  fresh  air, 
soon  causes  complete  and  safe  anaesthesia. 

The  Chloroform  Inhalers. — The  simplest  and  best  inhalers  are  Esmarch's, 
Skinner's,  and  Junker's  devices. 

EsmardCs  Inlialer  consists  of  a  properly  shaped  wire  framework  cov- 
ered with  flannel  and  so  arranged  that  it  may  be  fastened  to  the  head  (Fig. 
16).    A  few  drops  of  the  angesthetic  are  discharged  from  a  graduated  bottle 


Fig.  16. — Esmarch's  chloroform  inhaler. 


on  the  cloth  from  time  to  time  until  the  desired  effect  is  attained.  The 
flannel  covering  should  be  kept  dry  at  the  sides,  that  fresh  air  may  be  freely 
admitted  there  during  the  administration.  The  head  attachment  of  Es- 
march's inhaler  permits  the  ansesthetist  to  maintain  a  constant  scrutiny  of 
the  pulse  with  the  disengaged  hand. 

Shinner''s  Inhaler  and  bottle  differ  in  no  essential  respects  from  those 
of  Esmarch,  and  are  employed  in  a  similar  manner. 

Junker''s  apparatus  is  formed  of  a  hand  bellows  and  face-piece  con- 
nected with  a  graduated  bottle  for  the  anaesthetic  (Fig.  17).  About  an 
ounce  of  chloroform  is  put  in  the  bottle,  and  the  bottle  is  attached  by  the 
hook  to  a  garment  of  the  anaesthetist.  Then,  after  placing  the  face-piece 
in  proper  position,  aerated  chloroform  vapor  is  administered  by  gentle  pres- 
sure of  the  hand  bellows.  It  is  estimated  that  a  single  compression  of  the 
bellows  vaporizes  about  one  and  one  fifth  minim  of  chloroform,  provided 
that  the  fluid  be  at  a  temperature  of  55°  F.  If  a  flexible  metallic  tube  or 
tubes  with  fixed  curves  for  use  in  the  nose  and  throat  (Fig.  18)  be  substi- 
tuted for  the  face-piece,  the  vapor  can  be  discharged  deeply  into  the  mouth 


THE  GENERAL  CONSIDERATIONS. 


31 


or  throat  without  hindrance  to  the  operator,  in  cases  requiring  surgical  in- 
terference with  the  throat  or  palate.     The  availability  of  the  apparatus  to 
meet  this  requirement  appears  to  me  to  be  the  chief  advantage  that  it  offers 
over  the  other  inhalers.     If  care  be  not  taken  in 
this  method  of  use,  liquid  chloroform  will  be  dis- 
charged from  the  apparatus  instead  of  the  vapor. 

Occasionally  ether  and  cliloroform  are  employed 
interchangeably  in  the  same  case,  chloroform  being 


Fig.  17. — Junker's  apparatus. 


Fig.  18. — Nasal  and 
pharyngeal  tubes 
(Junker's  appara- 
tus). 


given  at  the  outset  with  the  view  of  avoiding  the  irritating  effects  of  the 
ether.  Again  ether  is  given  later  on  to  avoid  or  overcome  the  depressing 
influence  of  chloroform.  However,  great  pains  should  be  taken  on  such 
occasions  to  consult  the  safety  rather  than  the  comfort  of  the  patient. 

A.  G.  E.  Mixture. — This  fluid  is  composed  of  one  part  of  pure  ethylic 
alcohol,  two  parts  of  pure  chloroform,  and  three  parts  of  pure  ethylic  ether. 
The  mixture  has  an  agreeable  odor,  and  should  be  regarded  as  diluted  chloro- 
form and  be  administered  accordingly.  Esmarch's  or  Skinner's  apparatus 
(including  the  droppers)  should  be  employed  for  use  in  children  and  feeble 
adult  patients.  Allis'  inhaler  can  be  utilized  in  the  administration  to  the 
vigorous,  but  in  all  cases  a  liberal  supply  of  air  should  be  secured.  In  the 
latter  class  half  a  drachm  at  a  time  may  be  discharged  into  the  cone  ;  in  the 
former  the  fluid  is  sprinkled  on  the  inhaler  by  means  of  the  drop  bottle.  A 
uniform  evaporation  of  the  ingredients  is  necessary  for  the  best  results,  and 
therefore  small  amounts  should  be  employed  frequently,  rather  than  large 
ones  occasionally. 

A.  C.  E.  mixture  is  not  used  in  this  country  to  any  considerable  extent. 


32  OPERATIVE  SURGERY. 

The  sensitive  respiratory  membranes  of  the  young,  and  the  diseased  ones  of 
the  old,  are  irritated  but  little  by  it.  Persons  above  sixty,  those  who  are 
obese,  those  with  cardiac  or  pulmonary  disease  attended  with  dyspnoea  or 
cyanosis,  respond  satisfactorily  to  a  judicious  employment  of  this  mixture. 

The  dangers  and  the  discomforts  attending  the  administration  of  ether 
and  chloroform  have  called  for  the  outlay  of  much  time  and  effort  directed 
to  their  abolition.  Plowever,  the  recent  ingenious  devices  for  administra- 
tion, and  the  different  combinations  of  gases  and  vapors  with  decided  prac- 
tical advancement,  is  a  source  of  much  congratulation.  Schleicli,  of  Ber- 
lin, brought  forward  still  another  method,  the  claimed  safety  and  comfort  in 
the  use  of  which  are  based  on  the  relation  of  the  boiling  point  of  the  anaes- 
thetic to  the  rapidity  of  the  evaporation ;  the  more  rapid  the  evaporation, 
the  greater  the  comfort  and  the  less  the  danger  of  the  use,  and  vice  versa. 

The  following  three  mixtures  are  those  recommended  by  Schleich : 

Mixture  1. —  (Boiling  point,  100-2°  F.)  Chloroform,  45  parts;  petro- 
leum ether,  15  parts;  sulph.  ether,  180  parts. 

Mixture  2. —  (Boiling  point,  104°  F.)  Chloroform,  45  parts;  petroleum 
ether,  15  parts;  sulph.  ether,  150  parts. 

Mixture  3. — Boiling  point,  107*5°  F.)  Chloroform,  30  parts;  petro- 
leum ether,  15  parts;  sulph.  ether,  80  parts. 

The  boiling  point  of  the  petroleum  ether  should  be  between  140°  and 
149°  F.  An  ounce  of  the  No.  1  mixture  is  sufficient  for  an  operation  lasting 
twenty  minutes  or  so.  The  longer  the  operation  is  to  be,  the  higher  should 
be  the  boiling  point  of  the  anaesthetic,  as  such  angesthetics  evaporate  less 
rapidly,  and  therefore  exercise  a  more  profound  and  lasting  effect  on  the 
patient.  The  manner  of  giving  differs  in  no  essential  regard  from  that  of 
the  careful  administration  of  other  anesthetics  by  means  of  a  dropper,  and 
the  same  precautions  are  likewise  enjoined.  Extended  experience  in  their 
use  does  not  warrant  belief  that  these  mixtures  have  special  advantages. 

Nitrous  Oxide. — Nitrous  oxide  is  the  most  agreeable  and  safest  anes- 
thetic in  use,  and  the  death  rate  is  infinitesimal.  If  the  patient  have  heart 
disease,  kidney  disease,  or  phthisis,  nitrous  oxide  is  a  suitable  anesthetic;  but 
if  much  degeneration  of  the  vessels  or  aneurism  be  present  it  is  objectionable 
on  account  of  the  high  blood  pressure  it  causes.  The  administration  is  now 
principally  in  the  hands  of  specialists.  It  is  often  given  by  those  skilled  in 
its  employment  for  the  purposes  of  major  operations  when  other  anesthetics 
are  contra-indicated,  and  preliminary  to  the  use  of  ether  to  obviate  the  pri- 
mary discomfort  and  perhaps  alleviate  the  sequels  of  the  latter.  In  the  for- 
mer class  of  cases  the  anesthetic  state  is  often  prolonged  for  an  hour  or  more 
with  safety  to  the  patient.  However,  the  short  period  of  anesthesia,  un- 
familiarity  with  the  use,  and  the  completest  outfit  required  for  administra- 
tion hinder  the  general  adoption  of  this  meritorious  agento  In  some  hospi- 
tals it  is  highly  regarded  for  the  demands  of  simple  operations  and  the  mak- 
ing of  diagnoses  under  painful  circumstances.  But  inasmuch  as  the  use  of 
this  anesthetic  is  not  yet  practicable  in  a  general  surgical  sense,  any  desir- 
ing further  information  should  seek  it  of  those  who  are  skilled  by  experi- 
ence, and  from  the  special  literature  addressed  to  the  subject.     There  are 


THE  GENERAL  CONSIDERATIONS. 


33 


Fig.  19. — Bennett's  nitrous  oxide  inhaler, 


several  different  plans  of  administering  this  agent — viz. :  pnre,  mixed  with 
air,  or  mixed  with  oxygen.  Administered  in  a  pure  state,  the  resulting  ana3s- 
thesia  is  complicated  by  asphyxia  depending  upon  deprivation  of  oxygen. 
Given  in  combination  with  small  percentages  of  air,  complete  anesthesia 
may  be  induced  with  marked  lessening  or  absence  of  asphyxia.  In  combi- 
nation with  oxygen,  complete  ansesthesia  results  without  asphyxia. 

Dr.  Bennett's  gas  inhaler  (Fig.  19)  consists  of  three  parts — the  face- 
piece,  the  valve  chamber,  and  the  gas  bag.  The  face-piece  is  identical  with 
that  of  the  ether  inhaler.  A 
complete  description  of  Dr. 
Bennett's  inhalers  and  the 
method  of  their  operation  is 
provided  with  each  apparatus. 

Nitrous  Oxide  tvith  Oxy- 
gen is  unquestionably  the  best 
and  safest  form  of  nitrous- 
oxide  anaesthesia.  It  possesses 
all  of  the  favorable  character- 
istics of  the  latter,  and  is  to  a 
great  extent  free  from  the 
worst  of  its  unfavorable  feat- 
ures, i.  e.,  the  asphyxial  element,  to  which  may  be  attributed  practically  all 
that  is  dangerous  and  unpleasant  in  ordinary  nitrous-oxide  ansesthesia. 
The  unfavorable  characteristics  of  gas  and  oxygen  are  as  follows : 

1.  Difficulties,  inconvenience,  and  expense  of  the  administration. 

2.  Light  form  of  narcosis. 

3.  Failure  to  procure  satisfactory  anaesthesia,  in  a  small  percentage  of 
cases. 

1.  Gas  and  oxygen  is  vastly  more  difficult  to  administer  satisfactorily 
than  chloroform  or  ether,  requiring  considerable  experience  and  the 
closest  attention.  It  is  practically  impossible  to  move  the  patient  after 
this  anaesthetic  has  been  started  without  disturbing  the  narcosis.  It  is, 
therefore,  necessary  to  have  the  patient  upon  the  operating-table  before 
beginning  anaesthesia.  Any  other  position  than  the  supine  renders  the 
administration  too  difficult  to  be  practicable.  The  apparatus  is  large,  and 
is  apt  to  be  in  the  way  in  operations  about  the  head  or  neck.  It  is  neces- 
sary to  protect  the  tubes  through  which  the  gases  flow  from  pressure.  If 
stepped  upon  they  will  burst,  as  the  author  has  several  times  experienced. 
The  cost  of  a  long  administration  of  gas  and  oxygen  is  considerably  more 
than  ether  or  chloroform. 

2.  While  narcosis  may  be  carried  to  a  deeper  degree  with  gas  and  oxygen 
than  with  gas  alone,  it  occasionally  is  not  deep  enough,  which  is  especially 
true  in  rectal  and  abdominal  operations.  The  abdomen  is  peculiarly  apt  to 
remain  rigid,  even  though  the  narcosis  is  deep  and  free  from  signs  of  as- 
phyxia. Gas  and  oxygen  anaesthesia  is  not  recommended  in  intra-abdom- 
inal operations,  except  in  cases  in  which  the  advantages  more  than  offset 
this  particular  objection. 


34 


OPERATIVE  SURGERY. 


3.  Failure  to  produce  satisfactory  anaesthesia  is  exceedingly  rare,  and 
is  apt  to  be  the  result  of  faulty  administration.  However,  the  author  is 
convinced  that  there  are  patients  who,  with  fairly  skillful  treatment,  will 
not  pass  into  that  quiet  deep  narcosis  so  desirable.  These  patients  prob- 
ably belong  to  the  class  that  take  anaesthetics  badly,  requiring  large 
amounts,  and  exhibiting  marked  resistance  to  the  action  of  the  agent. 

The  Choice  of  Gas  ivith  Air  a?-  with  Oxygen  as  the  Ancesthetic. — The 
limitations  already  noted  regarding  the  scope  of  nitrous  oxide  for  surgical 
operations  indicate  its  field  of  usefulness.  In  the  writer's  judgment,  the 
chief  indications  for  employment  of  this  form  of  anaesthesia  are  found :  1. 
In  patients  who  are  more  than  usually  endangered  by  ether  or  chloroform, 
because  of  their  general  physical  state  or  on  account  of  the  presence  of  some 
special  pathological  condition.  Examples  of  this  class  are:  the  very  weak 
patients,  the  very  aged,  those  presenting  active  lesions  of  the  lungs,  the 
kidneys,  or  the  heart.  2.  In  operations  that  are  short  or  trivial  so  as  to 
render  the  effects  of  ether  or  chloroform  out  of  proportion  to  the  require- 
ments of  the  case.'  3.  In  patients  who  previously  have  suffered  unusually 
from  the  effects  of  ether  or  chloroform,  and  who  have  great  dread  of  these 
drugs.  The  administration  of  two  or  more  anaesthetics  in  succession  forms 
a  distinct  method  of  practice,  and  is  attended  with  numerous  advantages. 
Gas  before  ether,  consisting  in  the  administration  of  nitrous  oxide 
before  ether,  is  perhaps  the  best  example,  and  its  advantages  are :  the  indue- 
tion  of  unconsciousness  is  almost  ideal,  being  accomplished  in  from  ten  to 
twenty  seconds,  with  practically  no  discomfort.  Com.plete  ether  narcosis 
may  be  obtained  in  from  two  to  four  minutes  from  the  beginning  of  the 
gas,  with  entire  absence  of  a  stage  of  excitement. 

Chloroform  before  ether  is  frequently  resorted  to  in  order  that  the 
patient  may  have  the  comfort  of  the  more  agreeable  and  less  pungent  odor 

of  the  former  and  to  avoid  the 
mental    effect    often    produced 
upon  the  patient  by  the  more 
formidable    apparatus    used    in 
the  administration  of  the  latter. 
In  this  plan  it  should  not  be 
forgotten  that  a  large  percent- 
age of  the  deaths  from  chloro- 
form have  occurred  during  the 
early  part  of  its  administration. 
Chloroform  mixtures  before 
ether    are    less    dangerous    and 
nearly  as  pleasant.     Ethyl  bro- 
mide and  ethyl  chloride  before 
ether    produce    unconsciousness 
nearly   as   quickly   as   gas,   but 
are  less  pleasant  to  inhale.    The  succession  of  gas,  ether,  and  chloroform  is 
suitable  for  those  cases  in  which  the  latter  agent  is  indicated,  and  in  which 
it  is  desirable  to  avoid  the  conditions  noted  during  the  stage  of  excitement. 


Fig.  20. — Bennett's  "  gas  and  ether  "  inhaler. 


THE  GENERAL  CONSIDERATIONS.  35 

The  condition  of  the  respiration  and  circulation  under  nitrous  oxide  ren- 
ders the  succession  of  gas  and  chloroform  a  dangerous  procedure,  and  it 
should  not  be  undertaken. 

A  change  from  one  angesthetic  to  another  is  often  advantageous  during 
an  administration.  Thus  the  sedative  and  depressing  effects  of  chloroform 
are  counteracted  by  those  of  the  previous  or  subsequent  administration  of 
ether.  The  irritation  or  excessive  stimulation  of  ether  is  overcome  by 
changing  to  chloroform. 

The  administration  of  oxygen  during  anaesthesia  has  received  much 
attention,  especially  in  conjunction  with  nitrous  oxide,  which  when  given 
in  a  pure  state  is  complicated  by  asphyxia  resulting  from  deprivation  of 
oxygen.  Oxygen  has  been  recommended  in  conjunction  with  ether  and 
chloroform  by  numerous  observers,  and  while  it  is  probable  that  oxygen 
is  not  an  antidote  to  these  agents,  and  will  not  prevent  their  fatal  effects 
when  administered  in  an  overdose,  there  is  no  doubt  that  its  use  will  lessen 
or  obviate  the  asphyxia  which  frequently  complicates  their  administra- 
tion, thereby  removing  an  unpleasant  and  occasionally  dangerous  element 
of  the  narcosis. 

Experience  has  demonstrated  that  chloroform  and  ether  may  be  admin- 
istered in  such  a  manner  that  the  patient  does  not  suffer  from  lack  of 
oxj^gen,  and  it  is  therefore  evident  that  the  routine  use  of  this  agent  dur- 
ing ansesthesia  is  uncalled  for.  A  possible  danger  in  its  use  is  the  follow- 
ing :  "  The  supply  of  oxygen  keeps  the  patient  of  a  cherry-red  color,  and 
chloroform  is  pumped  on  until  the  respirations  stop  through  poisoning  of 
the  medulla.  ISTo  peripheral  duskiness  or  gradual  failure  of  respiration 
appears,  as  the  tissues  remain  red  until  circulation  and  respiration  cease." 
(Buxton.) 

MorpMn  with  Anaesthetics. — It  is  recommended,  and  with  much  force, 
to  administer,  hypodermically  or  otherwise,  a  small  dose  of  morphin  an 
hour  or  so  before  anaesthesia  is  commenced.  If  chloroform  is  to  be  em- 
ployed, the  dose  of  morphin  should  be  much  smaller  than  if  ether  is  used, 
and,  too,  the  administration  of  the  former  should  then  be  conducted  with 
the  greatest  care,  as  chloroform  acts  more  rapidly  and  profoundly  when 
morphin  has  been  given.  Morphin  ought  not  to  be  administered  while  the 
patient  is  under  complete  anaesthesia,  since  the  combined  effects  of  the 
drugs  may  cause  unpleasant  results  that  perplex  and  alarm  the  surgeon. 
It  is  advised  by  some  to  delay  giving  the  morphin  until  signs  of  returning 
consciousness  are  well  established,  as  then  the  cause  of  any  unexpected 
manifestations  can  be  the  better  interpreted.  The  morphin  quiets  the 
nervous  excitement  of  the  patient,  reduces  the  amount  of  the  anesthetic 
otherwise  necessary,  and  prolongs  its  effects,  lessens  the  tendency  to  nausea 
and  vomiting,  and  diminishes  shock.  This  plan  is  not  one  of  routine  prac- 
tice; it  is  used  with  great  discretion. 

Moderate    Inebriation. — Moderate  inebriation  with  brandy  or  whisky 

can  be  induced  in  advance  of  an  operation  for  injury  already  attended  with 

dangerous  shock;  and,  too,  this  plan  can  be  utilized  in  those  cases  that  are 

greatly  weakened  by  chronic  disease.     If  a  severe  operation  be  necessary 

5 


36 


OPERATIVE  SURGERY. 


under  the  above  circumstances,  the  patient  can  be  brought  to  a  state  of 
semi-intoxication  in  four  or  five  hours  by  the  administration  of  an  ounce  or 
two  of  brandy  or  whisky  every  hour  in  hot  milk  or  hot  beef  tea.  A  small 
dose  of  morphin  may  be  given  shortly  before  the  operation.  Now,  if  ether 
be  administered  in  the  usual  manner,  the  amount  required  will  be  small, 
and  the  analgesic  stage  will  be  sufficiently  prolonged  to  permit  the  perform- 
ance of  the  final  minor  details  of  the  operation,  without  the  further  use  of 
ether  or  the  causing  of  pain  and  annoyance  to  the  patient. 

Rapid  Respiration. — Rapid  respiration  will  cause  sufficient  analgesia  to 
permit  of  slight  operations,  as  the  passage  of  a  probe  or  sound,  the  manipu- 
lations of  inflamed  or  injured  parts,  without  pain.  The  effect  is  produced 
by  causing  the  patient  to  breathe  rapidly  for  two  or  three  minutes,  or  until 
there  is  a  tingling  of  the  extremities  and  surface,  attended  with  a  sense  of 
fullness  of  the  head,  dizziness,  and  confusion.  Those  who  suffer  from  or- 
ganic disease  of  the  heart,  lungs,  or  brain  should  not  attempt  this  measure. 

Local  AnsBsthesia. — ISTumerous  agents  are  known  that  will  cause  local 
anaesthesia.  The  majority  of  them,  however,  are  noted  more  as  ingenious 
exhibits  of  chemistry  than  of  practical  anaesthesia.  The  ones  commonly 
employed  are  ice,  ether,  chloride  of  ethyl,  cocain,  and  eucain. 

Ice. — Ice,  when  cracked  finely  and  combined  with  an  equal  amount  of  salt, 
restrained  by  a  rubber  or  gauze  in  closure,  and  applied  directly  to  the  part 
long  nough  to  cause  the  surface  to  become  pale,  bloodless,  and  numb  before 
the  incision  is  made,  is  serviceable,  and  requires  no  further  mention  here. 

Sterilized  fluids,  such  as  distilled  waters,  or  the  physiological  saline  solu- 
tion, may  be  injected  into  the  skin  in  small  amounts  by  a  hypodermic  syringe, 
causing  wheals  and  inducing  sufficient  angeesthesia  to  make  painless  minor 
operations  of  the  surface.  It  is  not  impossible  that  much  of  the  virtue 
of  dilute  medicated 
fluids  is  the  result 
of  a  mechanism  not 
unlike  that  of  sim- 
pler fluids. 

Ether. — Ether  is 
easily  obtained,  and 
can  be  readily  ap- 
plied by  means  of  an 
atomizer   (Fig.  21). 

The  pain  following  the  return  of  sensibility  is  often  more  severe  than  is  the 
immediate  suffering  from  the  operation  without  its  use.  The  tissues  ought 
not  to  be  frozen,  but  benumbed,  since  to  freeze  them  adds  to  the  pain  and 
retards  repair. 

Chloride  of  Ethyl— Chloride  of  ethyl  acts  in  a  similar  though  more 
painful  manner  than  ether,  and  can  be  easily  and  neatly  employed  by  com- 
pressing the  valve  controlling  the  nozzle  of  the  tube  in  which  it  is  offered 
for  sale  (Fig.  22).  This  auEEsthetic  can  not  be  readily  procured  in  most 
localities,  and  is  therefore  of  lesser  utility  than  ether.  It  must  be  carefully 
kept  in  a  cool  place.    Its  effect  is  produced  in  about  thirty  seconds. 


Fig.  21. — Richardson's  atomizer. 


THE  GENERAL  CONSIDERATIONS. 


37 


Pig  23.— Chloride  of  ethyl. 


Cocain. — Hydrochlorate  of  cocain  is  an  excellent  local  anEesthetic.  It  is 
applied  in  solution  to  all  mucous  and  cutaneous  surfaces,  and  also  is  in- 
jected into  the  tissues  beneath  these  surfaces  with  very  satisfactory  results. 
It  is  applied  to  mucous  surfaces  in  solutions  of  various  strengths,  usually 

from  five  to  twenty  per 
cent,  either  directly  by 
means  of  a  swab  or  through 
the  agency  of  a  spray.  It 
may  be  applied  to  the  cuta- 
neous surface  in  similar 
ways,  but  its  action  here  is 
comparatively  feeble  and  delayed;  therefore,  small  injections  into  the  skin 
are  preferred  to  relieve  the  pain  of  trivial  incisions.  Solutions  of  divers 
strengths  are  used  in  the  deeper  tissues,  the  strength  employed  depending 
on  the  amount  to  be  injected  and  the  character  of  the  contemplated  opera- 
tion. Ten  to  thirty  minims  of  a  four-per-cent  solution,  or  an  equiva- 
lent of  a  two-per-cent,  can  be  employed  subcutaneously  with  satisfac- 
tion in  minor  operations.  Even  much  weaker  solutions  are  not  infre- 
quently used. 

Briefly,  the  technique  of  injection  is  as  follows :  After  thorough  aseptic 
preparation  throughout,  insert  obliquely  the  tip  of  a  hypodermic  needle  at 
the  point  commanding  the  field  of  operation,  unless  hypersensitive,  into,  but 
not  entirely  through,  the  skin.  Inject  half  a  drop  or  so  of  the  fluid  and 
withdraw  the  needle;  make  an  incision  through  the  skin  for  half  an  inch, 
and  longer  if  pain  be  not  caused;  repeat  the  injection  into  the  skin  at 
either  angle  of  the  wound  and  extend  the  incision  the  desired  length ;  apply 
traction  to  the  benumbed  borders  only  and  draw  them  apart;  continue  the 
dissection,  repeating  the  injections  as  needed,  until  the  operation  is  com- 
pleted. The  amount  of  the  drug  employed,  and  the  rapidity  of  its  intro- 
duction, are  matters  that  must  be 
regulated  largely  by  the  judgment 
of  the  surgeon.  It  is  better  to 
introduce  the  needle  at  a  distance 
from  a  hypersensitive  point  rather 
than  into  it,  unless  the  sensation 
has  been  deadened  already  by  cold. 
Remarls.  —  When  thus  em- 
ployed, the  danger  of  use  increases 
correspondingly  with  the  amount 
injected.  Care  should  be  taken  to 
avoid  its  introduction  into  vessels 
and  nerves,  also  that  the  patient 
maintain  a  reclining  posture  until 
the  effects  shall  have  subsided ;  es- 
pecially if  the  amount  injected  be 
comparatively  large  or  the  patient  be,  for  any  reason,  unusually  susceptible 
to  its  influence.    Unfavorable  outcomes  of  various  degrees  seem  more  often 


Fig.  33. — Isolation  ring. 


Pig.  24.— Isola- 
tion forceps. 


38  OPERATIVE  SURGERY. 

to  happen  in  cases  when  the  stronger  solutions  have  been  applied  to  mucous 
membranes.  For  this  reason  a  combination  of  ethyl  chloride  and  a  medium 
strength  solution  of  cocain  may  be  employed  to  cause  surface  anges- 
thesia.  The  expedients  devised  for  limiting  the  action  of  this  drug  are 
ingenious  and  efEective.  Elastic  bandages  of  proper  width,  elastic  rings 
of  suitable  size  to  constrict  an  extremity,  metallic  rubber-covered  rings 
(Fig.  23),  and  isolation  forceps  (Fig.  24)  to  constrict  limited  areas,  are 
employed.    Figs.  25  and  26  illustrate  the  preceding  method. 

Regional  Pai'aneural  Infiltration  AncestJiesia. — In  this  procedure  the 
constricting  agent  is  placed  about  the  digit  or  other  portion  of  an  extrem- 
ity and  the  needle  is  introduced  at  a  short  distance  below  the  constricted 
point  and  the  tissues  about  the  nerves  are  infiltrated  with  the  fluid  by 
means  of  superficial  or  deep  injections,  according  to  the  depth  of  the  nerves 
from  the  surface  of  the  part  thus  treated.  A  suitable  degree  of  angesthesia 
is  secured  in  about  ten  minutes  for  operative  purposes.  The  amount  and 
strength  of  the  solution  injected  should  regulate  the  length  of  time  the  con- 
striction is  maintained.  If  weak  the  pressure  may  be  removed  at  once. 
KoliTbardt  determined  that  in  animals  a  toxic  dose  caused  a  fatal  effect 
when  liberated  within  fifteen  minutes;  but  if  restrained  from  thirty  to 
sixty  minutes,  the  toxic  symptoms  diminished  correspondingly,  all  subjects 
recovering,  and,  when  the  constriction  was  maintained  for  an  hour  or  more, 
no  toxic  effects  followed  the  removal  of  the  constricting  agent. 

Intraneural  Infiltration  Ancesthesia. — After  suitable  tissue  infiltration 
the  nerve  is  exposed  and  injected  with  a  one-per-cent  solution,  which  is 
soon  followed  by  angesthesia  of  the  areas  supplied  by  the  nerve  thus  treated. 
This  method  of  angesthesia  not  only  prevents  the  pain  incident  to  opera- 
tions, but  also  lessens  operation  shock  by  blocking  the  afferent  and  efferent 
impulses  of  the  nerve  in  question  (Crile).  One-half -of-one-per-cent  solu- 
tions are  employed,  and  even  half  of  these  strengths  may  be  effective  if  com- 
bined with  a  like  amount  of  a  physiological  saline  solution.  The  effect 
occurs  in  about  five  minutes,  and  lasts  three  or  four  times  as  long. 

Infiltration  Ancesthesia  (Schleich). — Infiltration  anaesthesia  consists  in 
the  hypodermic  introduction  into  the  tissue  of  weak  solutions  of  different 
combinations  of  cocain,  morphin  and  common  salt. 

No.  1  Solution,  Strong. 

Cocain  muriate ■ gr.  iij 

Morphin  muriate   gr.  § 

Soda  chloride gr.  iij 

Distilled  sterilized  water Siijt 

No.  2  Solution,  Normal. 

Cocain  muriate gr.  jss. 

Morphin  muriate   gr.  | 

Soda  chloride  g;r.  iij 

Distilled  sterilized  water oiijt 


THE  GENERAL   CONSIDERATIONS. 


39 


No.  3  Solution,  Wealc. 

Cocain  muriate gr.  h 

Morphin  muriate   gr.  § 

Soda  chloride    gr.  iij 

Distilled  sterilized  water §iij| 

Solution  ISTo.  1  is  employed  in  the  most  painful  operations,  and  as  many 
as  six  and  a  half  drachms  can  he  used  during  the  procedure. 

Solution  No.  2  is  employed  in  the  less  painful  ones^  and  three  ounces  and 
a  half  can  be  used  of  this. 

Solution  No.  3  is  injected  into  the  deeper  and  less  sensitive  tissues, 
and  employed  in  extended  operations.  Of  this  a  pint  can  be  used  at  a 
sitting. 

To  each  of  these  solutions  may  be  added,  for  obvious  reasons,  two  drops 
of  carbolic  acid.  In  incisions  limited  to  the  skin  sterile  saline  solution 
answers  the  purpose  quite  well.  In  instances  of  limited  infiltration  a 
hypodermic  syringe  can  be  used  (Fig.  29).  In  more  extended  uses  of  the 
fluid  larger  syringes  of  similar  construction  or  those  especially  designed  for 
the  purpose  may  be  utilized.     Of  the  special  kind,  the  one  devised  by  Matas 


Pig.  25. — Infiltration  of  deep  layer  of  skin, 


(Fig.  27)  is  of  great  practical  utility.  The  receptacle  is  filled 
through  the  bottom,  a  glass  guage  at  the  side  indicates  the 
amount  of  fluid  introduced.  Air  is  injected  into  the  receptacle 
passing  en  route  through  a  small  cylinder  filled  with  absorbent 
cotton  (Fig.  28).  This  and  similar  infiltration  devices  enable 
the  operator  to  promptly  and  continuously  introduce  the  fluid 
with  a  limited  number  of  punctures  of  the  tissue  for  the  purpose.       -p      <,„ 

The  Metliod  of  Introduction. — After  thorough  asepsis  intro-  Infiltration 
duce  the  needle  obliquely  into  the  deep  layer  of  the  skin  (Fig.  fin^sthesia. 
27) ;  inject  sufficient  fluid  to  cause  a  large  wheal ;  repeat  the 
injection  as  often  as  needed,  introducing  the  needle  at  the  advancing  border 
of  each  preceding  wheal,  so  as  to  avoid  the  sticking  pain  of  the  initial 
puncture;  incise  the  integument  along  the  line  of  the  infiltrated  area,  infil- 
trating the  deeper  tissues  in  turn  before  division;  infiltrate  independently 
large  nerves  in  the  line  of  the  incision  before  their  division ;  the  small  ones 
are  commonly  made  insensitive  by  the  tissue  infiltration ;  infiltrate  the  walls 


40 


OPERATIVE  SURGERY. 


of  arteries  and  veins  before  ligature  to  lessen  pain  of  tying ;  avoid  tearing 
and  stretching  of  tissues  during  dissection,  carefully  cutting  them  instead; 
avoid  undue  infiltration^  as  it  blurs  and  obscures  the  field  of  endeavor; 
obviate  the  danger  of  necrosis  of  tissues,  of 
infection,  and  suppu.ration  by  careful  dis- 
section and  the  use  of  sterile  agents ;  rein- 
filtrate  the  point  of  needle  puncture  when 
pain  attends  closure  of  the  wound  by 
sewing. 

The  General  Remarks. — The  perform- 
ance of  major  operations  by  this  method 
can  be  advised 
only  when  the 
greater  security  of 
the  patient  de- 
mands it,  usually 
in     instances     of 


great  exhaustion. 
The  preliminary 
injection  of  a 
small  dose  of  mor- 


FiG.  27. — Matas  infiltration  anaesthesia  apparatus. 


phin  at  proposed  seat  of  infiltration  often  adds  to  the  success  of  the  method. 
Dilute  solutions  of  cocain  should  alwa3^s  be  employed  in  prolonged  opera- 
tions. Familiarity  with  the  symptoms  of  cocain  poisoning  and  the  means 
of  relief  ought  to  be  fully  understood  and  at  hand.  During  the  operation 
an  assistant  should  watch  the  pulse  and  respiration  of  the  patient,  direct 
the  mind  from  the  operative  sensations,  and  otherwise  sustain  the  courage 
throughout.  It  is  better  to  depend  entirely  on  a  weak  solution  of  cocain 
than  to  lessen  the  etfects  of  the  stronger  by  combining  them  with  other 


Pig.  28. — Matas  apparatus,  introducing  the  air. 

drugs  of  less  potent  nature.  Local  angesthesia  is  often  supplemented  at 
intervals  with  general  chloroform  narcosis,  i.  e.,  "  morphin-cocain-chloro- 
form  angesthesia"  of  Schleich  and  Gushing.  GonJca  combines  the  electric 
current  with  a  four-per-cent  solution  of  cocain,  applied  by  means  of  gauze 
to  the  skin,  thus  obtaining  an  anesthesia  of  five  minutes'  duration,  sufficient 
to  permit  removal  of  large  skin  grafts.  Tropococain  is  milder  than  cocain, 
less  frequently  followed  by  ill  effects,  and  especially  commended  by  Schwartz 


THE  GENERAL  CONSIDERATIOXS. 


41 


for  spinal  ana?sthcsia.  Scldeich's  solution  ISTo.  2  is  most  commonly  em- 
ployed for  infiltration  purposes.  In  instances  of  extended  use  of  large 
amounts  of  the  fluid  the  morphin  may  be  inserted  at  first,  or  later  in  the 
course  of  the  dissection  to  avoid  any  unpleasant  effects  that  may  come  from 


'FpIo 


Fig.  29. — Pravaz  syringe  for  spinal  antesthesia. 


it.  This  fluid  may  be  supplemented  in  the  deeper  tissues  with  advantage  by 
the  use  of  the  sterile  salt  solution.  A  drop  of  carbolic  acid  applied  at  the 
seat  of  puncture  renders  penetration  painless.  A  solution  of  cocain  raised 
quite  to  the  boiling  point  two  or 
three  times  does  not  materially 
aJSect  its  anaesthetic  properties. 

Spinal  Ansesthesia. — To  Corn- 
ing belongs  the  credit  of  first  using 
the  spinal  injection  of  cocain  to  cause 
anfesthesia.  Spinal  ansesthesia  may 
be  employed  when  local  ansesthesia 
is  impracticable  and  general  anfes- 
thesia  is  contra-indicated  in  opera- 
tions of  magnitude.  A  Pravaz 
syringe  with  long  needles  of  relia- 
ble strength  or  apparatus  especially 
devised  for  the  purpose  may  be 
employed  (Figs.  29,  30).  The 
cocain  solution  should  certainly 
be  sterile.*  Sterilization  may  be 
attained  by  means  of  the  ordinary 
steam  sterilizer  (fractional  method), 
or  after  the  manner  of  Matas,  who 
dissolves  in  a  hundred  minims  of 
hot  sterilized  water  five  tablets, 
each  containing  one-fifth  of  a  grain 
of  cocain  hydroehlorat,  one-fortieth  .  « 
of  a  grain  of  morphin  hydroehlorat,  i '.  '  SL 
and  one-fifth  of  a  grain  of  sodium 


Fig.  30. — Tuffiers  spinal  syringe  for  spinal 
anesthesia. 


chlorid.      Twenty   minims    of   this 

solution  equals  the  strength  of  a 

single  tablet.     After  resterilization  by  the  fractional  method  twenty-two 

minims   are  injected,   thus  allowing  two   minims   for  waste   and  twenty 

*  W.  C.  Reilly,  N.  Y.  Med.  Record,  vol.  Ix,  1901,  page  213. 


42 


OPERATIVE  SURGERY. 


minims  for  medication.     The  fluid  should  be  at  about  the  temperature  of 
100°  F.  when  introduced. 

The  Operation  of  Injection  (Tuffier). — Seat  the  patient  on  a  table  with 
the  back  toward  the  operator,  the  hands  resting  on  the  thighs  to  support 
the  trunk ;  prepare  the  lumbar  region  with  antiseptic  care,  make  the  spine 
as  straight  as  possible  by  holding  the  trunk  nearly  upright;  identify  the 
highest  point  of  the  iliac  crests  posteriorly,  and  connect  them  with  a  hori- 
zontal line  (Figs.  31,  32)  ;  identify  the  tip  of  the  fourth  lumbar  spine  at  the 
point  it  is  crossed  by  this  line ;  introduce  the  needle  at  point  just  below  the 
outer  side  of  the  place  of  contact  of  the  line  with  the  spine,  passing  it 
in  a  slightly  upward  direction;  arrest  the  progress  of  the  needle  at  the 
first  appearance  of  cerebro-spinal  fluid, 
allowing  as  little  as  possible  to  escape;  Vs^^ 

exclude   air   from   the   syringe,    connect 
it  with  the  needle,  and  slowly  introduce 


Fig.  31. — The  anatomy  relating  to  the 
introduction  of  the  needle. 


Fig.  32. — The  needle  introduced. 


the  solution.  Within  three  minutes,  or  sooner,  analgesia  begins,  usually  at 
the  feet,  and  extends  upward  to  the  costal  arch,  aflecting  the  abdominal 
viscera,  sometimes  going  higher,  even  to  the  scalp.  The  effect  lasts  from 
twelve  minutes  to  three  hours  and  longer,  the  average  being  from  half  an 
hour  to  an  hour  and  a  half. 

Tlie  Precautions. — Spinal  ansesthesia  should  not  be  employed  except  for 
the  best  of  reasons,  as  it  can  not  safely  be  regarded  at  the  present  time,  as  a 
substitute  for  the  older  methods  of  practice.  Thorough  asepsis  of  all 
agents  concerned  in  the  act  should  be  assured.  The  usual  dose  is  fifteen 
minims  of  a  two-per-cent  solution.  Not  more  than  one  third  of  a  grain 
of  cocain  should  be  administered  at  one  time.    Familiarity  with  the  symp- 


THE  GENERAL  CONSIDERATIONS.  43 

toms  of  poisoning,  and  the  knowledge  and  availability  of  the  use  of  the 
remedial  agents  are  matters  of  great  importance.  Introduce  the  needle 
cautiously  to  avoid  the  bony  structure,  the  breaking  or  impairing  of  it,  and 
of  injury  to  the  intraspinal  nerves.  Inject  the  tluid  slowly,  using  quite 
a  minute  for  the  purpose.  Inject  the  solution  only  after  escape  through 
the  needle  of  cerebro-spinal  fluid,  as  this  alone  assures  that  its  extremity 
is  suitably  advanced.  Plugging  of  the  needle  by  fat  during  its  introduc- 
tion is  liable  to  happen,  causing  uncertainty  and  confusion  in  the  practice. 
For  this  reason  an  estimate  of  the  requisite  distance  of  introduction  of  the 
needle  should  be  made  before  trial,  so  that  plugging  can  be  quickly  detected, 
and  the  needle  partly  or  completely  withdrawn,  and  the  obstacle  dislodged 
by  a  fine  wire.  Carefully  note  that  no  bony  deformity  be  present  at  the 
established  seat  of  puncture  that  can  interfere  with  the  act.  Needles  espe- 
cially devised  to  prevent  plugging  are  commended. 

The  Comments. — Dr.  K.  W.  Morton,  whose  large  experience  in  spinal 
ansesthesia  commands  attention,  places  sterile  tubes  containing  crystals  of 
cocain  hydrochlorat  for  fifteen  minutes  in  a  dry  atmosphere  at  a  tempera- 
ture of  300°  F.  The  dose  employed  varies  from  0.3  to  0.5  grain.  The 
requisite  sized  dose  is  placed  into  a  sterile  syringe  with  a  glass  barrel  and 
the  piston  introduced.  The  patient  lying  on  the  side,  with  the  back  curved, 
the  needle  is  entered  between  the  spinous  processes  of  the  third  and  fourth 
lumbar  vertebrae,  passed  upward  and  forward  until  cerebro-spinal  fluid 
escapes  from  it.  The  barrel  of  the  syringe  is  then  connected  with  the 
needle,  the  piston  withdrawn  until  the  glass  chamber  is  half  filled  with 
cerebro-spinal  fluid.  As  soon  as  the  cocain  is  dissolved  the  fluid  is  slowly 
injected,  the  needle  withdrawn,  and  the  puncture  sealed  with  collodion. 
By  this  method  Morton  has  practiced  spinal  anaesthesia  673  times  without 
a  failure ;  *  60  of  which  were  produced  by  puncture  above  the  diaphragm. 
Morton  advises  that  the  concave  part  of  the  extremity  of  the  needle  be  dull, 
to  avoid  the  cutting  that  often  plugs  the  lumen  with  tissue.  Patterson 
estimates  the  death  rate  from  spinal  cocainization  at  about  3  in  1,000. 

Eucain  Hydrochlorat. — Although  this  drug  does  not  equal  cocain  in 
anaesthetic  effect,  it  no  doubt  is  the  most  potent  substitute.  Eucain  is  less 
toxic  than  cocain,  and  by  many  is  regarded  as  superior  and  safer,  espe- 
cially when  employed  in  the  urethra,  bladder,  and  upper  air  passages,  and, 
too,  in  connection  with  mucous  membranes  generally.  Solutions  of  one- 
to  four-per-cent  may  be  employed  independently  or  to  supplement  cocain 
when  the  latter  acts  unfavorably  in  the  course  of  an  operation.  Eucain 
sometimes  causes  sloughing,  especially  of  cutaneous  and  fatty  tissues. 
Eucain  is  not  impaired  by  boiling,  hence  can  be  thoroughly  sterilized.  Our 
experience  with  eucain  has  been  so  infrequent  as  not  to  afford  opportunity 
to  practically  judge  of  the  comparative  merits  of  the  drugs. 

Beta  Eucain. — Beta  eucain  is  thought  by  some  to  be  superior  to  eucain 
because,  while  possessing  all  of  the  virtues  of  the  latter,  it  is  less  often 
followed  by  pain  and  smarting  on  the  subsidence  of  anesthesia.     It  is 

*  Journal  of  the  American  Medical  Association,  Nov.  8, 1903. 


44  OPERATIVE  SURGERY. 

administered  by  direct  injection  and  by  the  infiltration  plan.  In  the 
former  five  to  seven  minims  of  a  two-per-cent  solution  are  employed,  in 
the  latter  five  or  six  ounces  of  a  solution  of  1  to  1,000  of  the  physiological 
saline  solution  can  be  used  during  an  operation.*  The  solution  should  be 
warm  when  introduced  into  the  tissues.  In  about  five  minutes  the  local 
effect  will  be  ample  for  the  purpose  intended,  and  after  twenty  minutes 
a  second  medication  will  probably  be  needed  if  further  operative  action  be 
required.  As  with  cocain  so  with  this  drug,  major  abdominal  and  else- 
where operations  have  been  performed  with  satisfactory  outcome  both  in 
ordinary  and  on  necessitous  occasions.  We  are  disposed  to  think  that  it  is 
better  that  the  surgeon  should  aim  to  consult  the  comfort  of  the  patient 
when  practicable,  rather  than  to  test  unusual  means  of  accomplishing  great 
results  in  an  astonishing  manner. 


THE  IlSrSTETJMENTS   NECESSAKY   TOR   THE   PEKEORMANCE   OP 
OPERATIONS. 

The  instruments  necessary  for  the  performance  of  an  operation  must  be 
regulated  by  the  magnitude  and  nature  of  the  procedure.  They  can,  how- 
ever, for  the  sake  of  brevity,  be  divided  into  those  in  general  use  and  those 
for  special  purposes. 

Tlie  Selection  of  Instruments. — The  selection  of  proper  instruments  for 
surgical  procedures  requires  especially  the  consideration  of  their  utility, 
construction,  and  quality.  The  pattern  of  the  instrument  should  conform 
to  the  accepted  standard  of  requirement.  Although  good  surgery  can  be 
done  with  clumsy  and  old-fashioned  instruments,  yet  the  more  delicately 
and  simply  formed  the  instruments  are  the  more  satisfactory  will  be  the 
labor  and  the  better  the  technique  of  the  procedure.  A  multiplicity  of 
instruments  devised  for  similar  purposes,  or  to  meet  fancied  or  shadowy 
indications,  or  to  exploit  the  name  of  the  inventor,  is  to  be  regretted. 

The  construction  and  finish  of  instruments  should  be  carefully  noted, 
and,  when  practicable,  they  should  be  made  in  a  plain  and  substantial  man- 
ner. The  handles  and  shanks  should  be  smooth  and  closely  adjusted,  or 
the  entire  instrument  made  of  metal  and  highly  polished.  Inequalities, 
and  mechanisms  that  can  lodge  impurities,  should  not  be  needlessly  tol- 
erated. All  lines  of  embellishment  and  the  stamp  of  the  manufacturer 
should  be  eliminated. 

The  standard  of  quality  of  cutting  instruments  can  be  estimated  by  the 
following  means : 

1.  By  drawing  the  cutting  edge  slowly  across  the  border  of  the  nail,  to 
detect  the  presence  of  nicks. 

3.  By  drawing  the  edge  in  the  same  manner,  with  the  blade  tilted,  across 
the  flat  of  the  nail,  to  determine  the  presence  of  a  soft  or  wiry  edge. 

3.  By  passing  the  point  of  the  instrument  through  tightly  stretched  kid 

*  Arthur  E.  Barker,  M.  D.,  Lancet,  January  30, 1900. 


THE   GENERAL  CONSIDERATIONS. 


45 


or  gold  beaters'  skin  ;  a  crackling  sound  will  be  caused  if  the  point  be  rough  ; 
otherwise,  it  will  pass  noiselessly  through  these  structures. 

4.  By  testing  the  edge  on  a  hair  held  between  the  thumb  and  finger,  as 
is  practiced  to  estimate  the  cutting  edge  of  a  razor.  The  acuteness  can  be 
determined  by  shaving  a  few  hairs  from  the  back  of  the  clinched  hand  of 
the  operator  or  an  assistant. 

The  variety  and  extent  of  the  armamentarium  of  a  surgeon  should  de- 
pend on  the  present  and  prospective  demands  for  his  services.  Those  who 
can  avail  themselves  of  easy  access  to  the  business  places  of  instrument  mak- 
ers and  dealers  in  surgical  supplies  are  seldom  at  a  loss  to  secure  the  neces- 
sary instrument  at  once  ;  but  those  who  are  distant  from  the  base  of  sup- 
plies must  necessarily  possess  the  instruments  which  their  professional  en- 
vironment suggests,  many  of  which  may  rarely,  if  ever,  be  called  into  use. 

The  ingenious  and  comprehensive  outfits  now  offered  for  sale  in  the  form 
of  pocket  cases  and  special  and  general  operating  cases  and  bags,  and  emer- 
gency outfits,  enable  one  to  provide  reasonably  for  all  probable  requirements. 
The  exercise  of  good  judgment  and  reasonable  forethought  on  the  part  of 
surgeons  will  cause  them  to  utilize  many  instruments  for  divers  purposes, 
and  thus  lessen  the  expense  and  also  limit  the  production  of  instruments  to 
within  the  bounds  of  reason  and  expediency. 

The  instruments  in  general  use  include  scalpels  and  bistouries  of  various 
forms  (Fig.  33),  thumb  forceps,  grooved  directors,  and  scissors.  Those  for 
special  purposes 
are  employed  in 
the  performance 
of  operations 
which  in  most 
instances  caused 
their  creation  ; 
they  will  be 
considered  in 
connection  with 
the  operations 
to  which  they 
are  particularly 
adapted. 

The  Methods 
of  Holding  the 
Scalpel.  —  Three 
positions  are 
commonly  rec- 
ommended, each  of  which  is  subdivided  into  two.  The  positions  resemble 
the  manner  of  holding  respectively,  the  ordinary  table  knife,  the  pen,  and 
the  violin  bow. 

Figs.  34  and  35  represent  the  subdivisions  of  the  first  position;  they  in- 
dicate that  force  and  firmness  are  required.  Figs.  36  and  37  represent  the 
subdivisions  of  the  second  position ;  these  are  taken  when  quick,  delicate, 


Fig.  33. — Scalpels  and  bistouries. 


46 


OPERATIVE   SURGERY. 


and  precise  movements  are  made.  Figs.  38  and  39  are  the  subdivisions  of 
the  third  position,  and  are  employed  when  caution  is  used  in  conjunction 
with  delicacy  in  cutting. 

The  preceding  positions  are 
more  essential  to  graceful  than 
to  successful  operative  methods. 


Fig.  ;]4. 


Holding  knife,  first  position. 


The  Thumb  Forceps  (Fig.  40). — The  thumb  forceps  is  used  in  connection 
with  the  scalpel  or  scissors.  It  is  employed  to  pick  up  portions  of  tissues,  such 
as  the  fascia,  which  are  to  be  removed  or  incised  near  to  the  point  grasped,  for 


Fig.  36. 


Holding  knife,  second  position. 


Fig.  37. 


various  reasons.  The  scalpel,  or  bistoury,  should  be  held  at  nearly  a  right 
angle  to  the  forceps  when  the  incision  is  made,  especially  when  important 
structures  lie  immediately  beneath  the  line  of  incision.     The  tissue  may  be 


Fig.  38. 


Fig.  39. 


Holding  knife,  third  position. 


grasped  at  each  side  of  the  median  line  of  the  wound  with  forceps,  and  the 
'division  be  made  directly  downward  upon  a  vessel  or  other  important  struc- 


THE  GENERAL  CONSIDERATIONS. 


47 


tiire  (Fig.  41).  This  plan,  when  supplemented  with  gentle  separation  of  the 
tissues  with  retractors,  is  technically  superior  in  all  respects  to  the  one  in 
which  a  grooved  director  is  employed.  The  spring  of  the  forceps  should 
be  quick  and  not  too  strong,  and  the  bite  wide,  to  secure  ease  and  certainty 
of  execution  and 
limit  the  bruising 
of  the  tissues 
grasped  to  a  mini- 
mum. Unneces- 
sary   pinching    of 

tissues  by  forceps  must  be  avoided,  as  repair  of  the  wound  is  thereby  hin- 
dered, and  non-union  may  result.     The  injury  of  the  tissues  from  forci- 


FiG.  40. — Thumb  forceps. 


Fig.  41. — Cutting  between  forceps. 

pressure  can  be  lessened,  and  in  fact  almost  obviated,  by  the  use  of  for- 
ceps with  the  claw-shaped  bite  (Fig.  42).  However,  the  narrow  bite  of 
this  implement  ex- 


poses  the  tissues  to 
greater  danger  of 
laceration,  unless 
the  degree  of  force 
exercised  be  pro- 
portionately regu- 
lated. 

The  Grooved  Di- 
rector (Fig.  43). — The  grooved  director  is  employed  to  separate  and  raise 
those  tissues  which  are  to  be  divided  with  caution.  The  director  should 
be  five  or  six  inches  in  length,  depending  upon  the  extent  of  the  incision 
and  the  depth  of  the  wound  into  which  it  is  to  be  inserted ;  it  should  be 
flexible,  with  a  broad  extremity  for  grasping,  and  a  pocket  at  the  end  of 
the  groove  to  arrest  the  point  of  the  knife  or  scissors.  The  end  of  the 
instrument  should  not  be  pushed  beyond  the  extremities  of  the  external 


Pig.  42. — Claw-bite  forceps. 


48 


OPERATIVE  SURGERY. 


incision,  because  of  the  danger  of  making  pockets  there  in  the  soft  parts, 
which  will  provoke  inflammation  and  impede  drainage.  The  tissues  raised 
upon  the  director  should  be  divided  within  these  extremities.     Care  should 


Fig.  43. — Grooved  director. 


be  taken  when  the  director  is  passed  between  a  serous  membrane  and  its 
superimposed  fascia  that  the  membrane  does  not  fold  over  the  advancing 
extremity,  thereby  causing  it  to  be  prematurely  punctured  or  divided  by  the 
knife  or  scissors.  Many  operators  employ  the  director  but  rarely.  On  the 
contrary,  not  a  few  use  it  as  a  blunt  dissector,  to  tear  asunder  tissues  during 
operative  procedures.  While  it  is  no  doubt  true  that  this  instrument  is  em- 
ployed unwisely  on  frequent  occasions,  still  the  comfort  and  security  that  its 
proper  use  affords  to  inexperienced,  timid,  or  even  discreet  operators  justi- 
fies its  retention  in  a  surgical  outfit. 

The  Scissors. — The  scissors  is  sometimes  used  as  a  substitute  for  the 
scalpel  for  deep  and  cautious  cutting  in  a  limited  space.  Less  oozing  of 
blood  follows  its  use  than  that  of  the  scalpel,  on  account  of  the  crushing 


Pig.  44. 

Straight  scissors. 


Pig.  45. 
Curved  on  the  side. 


Fig.  46. 
On  the  flat. 


Fig.  47. 
On  the  flat. 


nature  of  its  cutting  force.  Curved  on  the  flat  blunt-pointed  scissors  (Fig. 
46)  can  be  handily  utilized  as  dry  dissectors,  to  separate  and  push  aside  tis- 
sues that  impede  the  progress  of  an  operation  or  lie  in  contact  with  morbid 


THE  GENERAL  CONSIDERATIONS. 


49 


growths.  Scissors  should  he  so  constructed  as  to  readily  meet  the  purposes 
of  their  use;  they  may  be  straight  (Fig.  44),  curved  on  the  side  (Fig.  45)  or 
on  the  flat  (Fig.  46),  with  long  or  short  handles,  long  or  short  blades,  sharp 
(Fig.  47)  or  dull  points,  etc.  Sharp-pointed  scissors  can  be  used  to  make 
the  channels  in  tissues  in  which  drain- 
age tubes  are  placed.  If  the  sharp 
points  of  the  scissors,  while  closed,  be 
carried  through  the  tissues  guided  by 
the  fingers  within  the  wound,  to  the 
external  surface,  and  their  withdrawal, 

while    opened,  be  followed   closely  by    Fm.  48.— A  manner  of  holding  scissors, 
suitable  forceps   or   forcipressure,  the 

drainage  tube  can  be  caught  and  pulled  into  position  with  a  maximum 
accuracy  of  adjustment  and  a  minimum  degree  of  danger  to  the  inter- 
vening structures.  A  graceful  and  delicate  method  of  holding  the  scissors 
(Fig.  48),  adds  quite  as  much  to  the  style  of  the  operator  as  do  similar 
methods  of  holding  the  scalpel. 

Blunt  Dissection. — Blunt  or  dry  dissection  is  practiced  by  a  blunt  imple- 
ment (see  scissors)  devised  for  the  purpose,  and  employed  to  supplement  the 
use  of  cutting  instruments  in  the  approach  and  removal  of  morbid  growths 


Fig.  49. — Levis's  blunt  dissector. 


associated  with  important  structures  (Fig,  49).  These  agents  separate  in- 
stead of  dividing  the  tissues,  thereby  permitting  cautious  advance  without 
wounding  the  important  vessels  and  nerves.  Their  use  is  especially  indi- 
cated in  the  removal  of  tumors  from  the  deep  structures  of  the  neck. 

Incisions. — The  varieties  of  incisions  are  numerous,  and  are  classed  ac- 
cording to  the  direction  in  which  they  are  made — as  the  straight,  curved, 
cross-shaped,  etc.  The  choice  of  incision  is  determined  largely  by  the  under- 
lying anatomy,  the  contour  of  the  growth  to  be  removed,  the  establishment 
of  good  drainage,  the  avoidance  of  disfigurement  of  the  patient,  and  the 
cleavage  of  the  skin.  Incisions  made  in  the  lines  of  cleavage  of  the  skin 
gape  but  little,  unite  promptly,  and  with  a  minimum  degree  of  scarring.  In- 
cisions for  drainage  purposes  should  be  made  at  right  angles  with  the  lines 
of  cleavage,  if  the  retractive  tendency  of  the  skin  alone  is  relied  upon  to 
maintain  the  patency  of  the  opening.  If  drainage  agents  are  employed,  the 
direction  of  the  incision  is  less  important. 

The  length  of  an  incision  is  controlled  by  the  special  requirements  of  an 
operation.  It  should  be  long  enough  to  permit  a  good  view  of  the  parts 
involved,  and  an  expeditious  and  proper  treatment  of  the  abnormal  and  the 
healthy  tissues.  An  incision  can  be  lengthened  from  time  to  time  as  the 
necessities  require.  There  is  greater  danger  of  making  an  incision  too  short 
than  too  long,  and  of  the  two  the  former  is  the  greater  evil,  since  a  long, 
clean-cut  incision  will  drain  better  and  heal  quicker  than  a  short  deep  one 
bounded  by  tissues  that  have  been  bruised  and  torn  by  the  efforts  directed  to 


50 


OPERATIVE  SURGERY. 


the  accomplishment  of  a  definite  purpose  within  a  too  limited  space.  The 
fear  of  disfigurement  from  an  incision  ought  not  to  invite  disaster  by  an 
unwise  limitation  of  its  extent. 

Before  the  incision  is  formed,  the  integument  to  be  divided  should  be 
made  tense  at  either  side  by  opposing  forces  gently  and  equably  employed 
(Fig.  169).  If  this  precaution  be  not  observed,  the  relaxation  of  the  re- 
leased tissues  after  division  will  cause  the  incision  to  fall  outside  of  the 
proper  line  of  action  in  the  deeper  structures,  and  impaired  view,  unwise 
manipulation  of  the  tissues,  bad  drainage,  and  unnecessary  scarring  will  fol- 
low, unless  another  and  a  suitable  division  be  made.  This  error  often 
happens  when  an  assistant  incautiously  endeavors  to  aid  the  operator  in 
the  movement. 

Primary  incisions  should  be  clean-cut  from  end  to  end,  and  the  tissues 
beneath  should  be  as  cleanly  cut  or  carefully  separated  as  circumstances 
will  permit.      The  tearing  apart  of  tissues  with  the  finger,  handle  of  the 

scalpel,  or  other  device,  must  be  carefully 
avoided,  as  unwise  and  unguarded  methods  of 
this  kind  foster  delay  in  repair,  imperfect 
drainage,  and  therefore  unsatisfactory  results. 

Deep  dissections  should  be  made  in  a  more 
careful  manner  than  the  superficial,  and  as 
near  to  the  immediate  environment  of  the 
abnormal  condition  as  good  judgment  indi- 
cates. Both  superficial  and  deep  incisions  and 
separations  of  tissues  should  be  made  as  nearly 
as  possible  in  the  line  of  the  course  of  the 
vessels,  nerves,  and  the  muscular  fibers  that 
fall  in  their  way.  The  uppermost  dissections 
should  be  made  first,  so  that  the  bleeding 
caused  by  them  will  not  obscure  the  subsequent 
steps  of  the  operation. 

During  the  course  of  an  operation  carried 
on  through  an  incision  of  the  soft  parts  the 
borders  of  the  wound  should  be  held  asunder 
so  as  to  permit  of  a  good  view  and  proper 
manipulation  of  the  deeper  structures.  For 
this  purpose  variously  formed  retractors  have 
been  devised  (Fig.  50) — those  with  sharp  hooks, 
blunt  hooks,  etc.  (Fig.  175).  Operations  of  a  complicated  or  special  nature 
require  special  retractors,  and  these  will  be  illustrated  in  their  proper  places. 
If  the  retractors  be  cumbersome  and  in  the  way,  long,  strong  silk  traction 
loops  can  be  passed  deeply  through  the  center  of  each  side  of  the  wound, 
tied  or  not,  caught  with  forceps,  and  drawn  apart  by  the  assistant  or  by  a 
suitable  weight  attached  to  the  ends  (Fig.  51).  This  idea  is  especially  ser- 
viceable in  limited  spaces,  as  in  perineal,  axillary,  and  tracheal  incisions. 

Antiseptic  and  Aseptic  Methods. — In  the  brief  study  of  the  remaining 
essential  requirements  the  expressions  antiseptic  and  aseptic  frequently  ap- 


FiG.  50. — Retractors. 


THE  GENERAL  CONSIDERATIONS. 


51 


Xiear;  but  since  each  signifies  a  like  oulconic,  ilieii-  dissiiuilai'ity  will  not  be 
stated  until  later  on  (page  94). 

The  Receptacles  for  Instruments. — The  receptacles  for  instruments  vary 
in  shape  (Fig.  52),  size,  and  in  material,  according  to  the  fancy  of  the  de- 


FiG.  51. — Traction  loops. 

signer,  the  size  of  the  instruments,  and  the  nature  of  the  antiseptic  fluids 
employed.  The  number,  too,  should  conform  to  the  convenience  of  the 
operator  and  the  demands  of  the  occasion.  Under  all  circumstances  the 
receptacles  should  be  thoroughly  cleansed  by  scrubbing  and  boiling  before 
the  antiseptic  fluids  are  put  into  them. 

They  should  be  tight,  and  of  sufiicient  depth  to  permit  of  complete  im- 
mersion of  the  instruments  in  the  purifying  fluid.     Wooden  receptacles  are 


Fig.  52. — Kidney-shaped  receptacle. 


Fig.  53. — Gutta-percha  receptacle. 


Fig.  54. — Glass  receptacle. 


Pig.  55.— Autlior's  rubber  receptacle, 
with  metal  frame. 


not  suitable  for  the  purpose,  as  one  can  not  be  certain  that  they  are  in  a 
cleanly  condition.    Rubber,  gutta-percha  (Fig.  53),  papier-mache,  porcelain, 
earthen-,  glass-  (Fig.  54),  and  agate-ware  receptacles  are  cheap,  common, 
6 


52 


OPERATIVE  SURGERY. 


and  serviceable.  Tin  receptacles,  while  always  available,  are  unsuited  for 
the  use  of  mercurial  solutions.  Rubber  receptacles  that  may  be  folded  so 
as  to  occupy  but  limited  space  are  cheap,  portable,  durable,  and  convenient. 
The  one  designed  by  the  author  (Fig.  55)  can  be  employed  with  or  without 
the  metal  framework  belonging  to  it,  depending  on  whether  or  not  it  is  to 
be  moved  while  in  use.  If  the  support  of  the  framework  be  omitted,  the 
receptacle  can  not  be  moved,  except  with  great  care,  without  the  danger  of 
slopping  over.  The  rubber  receptacle  with  a  hollow  elevated  border  ad- 
mitting of  inflation  is  also  convenient  and  portable,  but  is  liable  to  collect 
objectionable  matter  in  the  retiring  angles  of  the  sides,  which  may  escape 
observation  and  become  the  source  of  infection. 

As  every  instrument  employed  in  an  operation  should  he  thoroughlg  steril- 
ized before  it  is  handled  or  brought  in  contact  with  the  field  of  procedure, 
it  is  necessary  to  exercise  great  care  to  secure  this  desideratum.  For  this 
purpose  the  instruments  should  be  carefully  wrapped  in  a  clean  towel,  and, 
while  thus  surrounded,  placed  in  a  suitable  receptacle  containing  pure  water 
or  the  soda  solution  (page  62)  and  boiled  for  not  less  than  half  an  hour ;  then, 
while  yet  surrounded  by  the  towel,  they  are  promptly  immersed  in  the  anti- 
septic fluid,  unwrapped,  and  placed  in  suitable  and  separate  receptacles 
already  supplied  with  antiseptic  fluid,  in  which  they  remain  until  required 
for  use.  Before  boiling,  the  blades  should  be  unlocked  to  insure  asepsis,  and 
the  cutting  edges  wrapped  in  cotton  to  prevent  dulling.  Solutions  of  carbolic 
acid,  of  beta-naphthol,  or  of  Thiersch's  fluid  are  suitable  for  immersion  pur- 
poses, as  they  cause  no  deleterious  effects  on  the  cutting  edge.  While  dif- 
ferent sterilizers  are  designated  in  which  to  boil  in- 
struments, it  is  often  more  a  matter  of  convenience 
than  necessity  in  private  practice  that  one  is  em- 
^  niifi  '  *^'*'  '^  ployed,  since  in  any  household  a  suitable  utensil  can 
|j'<«*g|jp  t  'be  quite  easily  procured  and  cleansed  for  this  purpose. 

V  P^     II      '^w,^  ^  The  different  kinds  of  portaUe  (page  113)  and  of 

fixed  sterilizers  for  office  and  hospital  work,  with  a 
detailed  statement  of  their  management,  can  be  pur- 
chased at  the  depots  for  surgical  supplies.  A  tin- 
smith can  make  a  serviceable  one  by  fitting  within  a 
copper  receptacle  of  suitable  size  and  with  a  movable 
top,  a  perforated  tin  tray  upon  which  the  instru- 
ments are  placed  and  immersed  within  the  fluid  in 
the  copper  vessel  and  boiled. 

If  the  number  of  assistants  le  limited^  or  if  they 
be  inexperienced  or  careless  in  shifting  the  instru- 
ments to  and  from  the  fluid  during  the  operation, 
the  receptacles  can  be  so  placed  as  to  allow  the  oper- 
ator to  take  charge  of  this  duty  himself.  In  order 
that  this  demand  can  be  properly  and  promptly  met,  the  author  has  devised 
a  rotary  framework  on  which  are  firmly  placed  several  receptacles  for  instru- 
ments (Fig.  56),  which  are  brought  into  use  by  turning  the  platform  on 
which  the  receptacles  are  placed,  as  occasion  requires.     The  fluids  in  these 


Fig.  56. — Author's  rotary 
receptacle. 


THE  GENERAL  CONSIDERATIONS. 


53 


receptacles  can  be  readily  discharged  when  necessary  through  a  rubber  tube 
adjusted  to  a  spigot  in  the  corner  of  each.  This  apparatus  is  too  cumber- 
some for  use  in  other  than  office  or  hospital  work. 

The  Operating  Table. — The  securing  of  light,  freedom  of  action,  and 
cleanliness  in  operations  require  that  the  patient  be  placed  on  some  form  of 
operating  table  during  these  procedures.  If  the  operation  be  trivial,  it  is 
better  not  to  excite  the  apprehensions  of  the  patient  and  friends  by  un- 
necessary preparations,  but,  instead,  to  utilize  for  the  purpose  the  ordinary 
couch  or  lounge  that  is  at  hand  in  most  instances.  However,  the  opera- 
tions that  require  the  free  use  of  anaesthesia  and  fluids,  careful  observa- 


Extemporized  operating  table. 


tion,  and  are  attended  with  much  expenditure  of  time  and  method,  require 
that  special  provisions  be  made  for  the  purpose  of  properly  supporting  the 
patient. 

Operating  tables  may  be  of  established  form,  or  contrived  at  the  time 
of  the  demand  by  the  utilization  of  the  ordinary  tables  and  stands  that  are 
a  part  of  the  belongings  of  every  household  (Fig.  57).  These  articles,  when 
placed  in  proper  position  and  covered  with  old  blankets  and  water-tight  asep- 
tic rubber  sheets,  answer  well  the  purposes,  unless  the  patient  be  violent ; 
then  the  struggles  will  frequently  disarrange  the  outfit.  Each  detail  of  the 
preparation  of  an  operating  table  should  be  adjusted  carefully,  in  order  to 
obviate  the  unnecessary  soiling  or  disfigurement  of  the  furnishings  of  the 
premises.  The  caretakers  of  household  matters  have  a  keen  appreciation 
of  any  efforts  that  may  be  directed  to  the  prevention  of  needless  soiling  or 
disfigurement  of  household  articles  on  these  occasions,  not  so  much  on  ac- 
count of  their  intrinsic  worth  as  the  unpleasantness  of  the  recollections  sug- 
gested later  by  their  presence. 


54 


OPERATIVE  SURGERY. 


The  width  of  the  table  should  permit  the  operator  and  the  assistants 
to  stand  close  to  the  patient,  and  it  should  be  so  tilted  or  constructed  as 
to  cause  all  fluids  connected  with  the  operation  to  be  promptly  dis- 
charged into  suitable  receptacles  jjlaced  at  the  side  or  foot  of  the  table. 
The  rubber  sheeting  j^laced  beneath  the  patient  can  be  folded  and  raised  at 
the  sides  by  thin  pieces  of  wood  or  sand  bags  so  as  to  limit  the  spread  of 
fluids  to  the  part  of  the  patient  immediately  beneath  the  field  of  operation. 
Pieces  of  rubber  tubing  can  be  placed  transversely  immediately  under  the 


Fig.  58. — Kelly's  large 
surgical  cushion. 


Fig.  50.— Kelly's  small 
surgical  cushion. 


Fig.  60.— The  Boston  sur- 
gical cushion. 


patient  above  and  below  the  seat  of  o]x>ration  for  the  same  purpose.  This 
aim  should  be  earnestly  sought,  as  unnecessary  wetting  deepens  shock, 
exposes  the  patient  to  taking  cold^,  and  also  increases  the  task  of  properly 
cleansing  and  wiping  the  surfaces  after  the  operation.  The  rubber  surgical 
cushions  now  in  common  use  are  both  convenient  and  serviceable  in  this 
regard  (Figs.  58,  59.  (iO). 

The  operating  table  of  comprehensive  pattern  ought  to  possess  the  fol- 
lowing characteristics : 

1.  It  should  permit  the  elevating  and  lowering  of  the  head  of  the  pa- 
tient, so  as  to  secure  for  the  operator  and  the  patient  every  advantage  aris- 
ing from  the  influences  of  the  force  of  gravity.  The  surgeon  is  aided  in 
many  operations  on  the  abdominal  contents,  and  the  patient  is  sometimes 
benefited  by  this  maneuver.  But  the  good  points  of  this  device  are  often 
overdone,  since  they  may  be  unwisely  employed  or  unnecessarily  prolonged 
to  the  disadvantage  of  the  patient  and  the  discredit  of  the  method.  The 
operating  table  devised  by  Cleveland  is  made  entirely  of  wrought  iron,  and 
is  so  constructed  as  to  permit  the  placing  of  the  patient  in  almost  any  re- 


THE  GENERAL  CONSIDERATIONS. 


quired  pogitions  (Figs.  61,  62).    Fowlers  operating  table  can  be  promptly 
adjusted  to  rrif-ftt  surfrioal  need,  and  is  p^o^^ded  also  with  a  platform  of 


Fro.  61. — Cleveland's  operating  table. 

tubes  containing  water  of  proper  temperature  througli  which  the  patient  is 
supplied  with  warmth  (Figs.  63,  6-1:,  65).  C rile'' 8  hot- water  mattress  may 
be  used  on  any  table  with  satisfaction. 

2.  It  should  cause   the  prompt  discharge  of  all  fluids  away  from  the 
patient.     Inasmuch  as  all  surgical  paraphernalia  are  being  constantly  modi- 


FiG-  62. — Cleveland's  table,  Trendelenburg  position. 


fied  to  conform  to  the  special  and  newly  born  demands  of  surgical  advance. 
one  contemplating  the  purchase  of  a  special  article  of  this  kind  should  con- 
fer with  those  in  active  touch  with  improved  technique,  rather  than  rely 
entirely  on  the  belated  representations  of  surgical  tomes.  Xo  surgeon  should 
so  exaggerate  the  demands  of  an  occasion  as  to  require  the  procurement  of  a 


66 


OPERATIVE  SURGERY. 


special  operating  table,  when  the  exercise  of  reasonable  forethought  and 
ingenuity  on  his  part  will  enable  him  to  meet  the  necessary  requirements  by 
the  utilization  of  the  resources  near  at  hand. 


Fig.  63. — Fowler's  operating  table.     First  position. 

PortaNe  Operating  Tables. — The  table  of  Pryor  (Figs.  67,  68),  and  that 
of  Edebohls  (Figs.  69,  70),  are  notable  examples  of  numerous  patterns  of 
this  kind  of  support. 


Fig.  64. — Fowler's  operating  table.     Second  position. 


A  portable  inclined  plane  for  pelvic  elevation  is  very  serviceable,  and 
can  be  adjusted  by  fixing-clamps  to  any  table  (Fig.  71). 

An  improvised  inclined  plane  for  pelvic  elevation  can  he  made  with  an 
ordinary  chair.  The  top  of  the  back  and  the  front  of  the  seat  of  the  chair 
should  rest  on  the  table,  with  the  legs  in  the  air.  The  patient's  extremities 
are  bound  to  the  front  rungs  and  his  back  laid  upon  the  back  of  the  chair. 
The  chair  may  be  fastened  to  the  table  on  which  it  rests. 


THE   GENERAL   CONSIDERATIONS. 


57 


Tlte  Empty  Vessels. — An  ample  supply  of  aseptic  empty  vessels,  con- 
sisting of  pails,  basins,  pitchers,  etc.,  should  always  be  provided,  whether 
the  operation  be  performed  in  a  hospital  or  elsewhere.     The  careful  and 


Pig.  65. — Fowler's  operating  table.     Third  position. 

orderly  disposal  of  soiled  articles  and  waste  of  all  kinds  is  an  earnest  of 
thorough  work  in  other  respects.  Soiled  textile  fabrics  and  sponges  should 
be  put  at  once  where  they  can  not  beconie  the  sources  of  present  or  pros- 
pective infection.  Pails  for  cold  water ;  pitchers  for  cold  and  hot  water, 
and  antiseptic  solutions ;  basins  for  clean  and  soiled  sponges  and  wipers,  and 
to  contain  antiseptic  fluids  for  every  established  purpose  in  an  operation, 
should  be  freely  provided.  The 
receptacles  for  antiseptic  fluids 
should  be  legibly  tagged,  stating 
the  nature  and  strength  of  their 
contents,  to  avoid  confufusion 
and  mistakes. 

A  deep,  oblong  basin  (Fig, 
72)  containing  an  antiseptic  or 
aseptic  solution,  in  which  the 
surgeon  can  lave  the  forearms 
and  hands  for  a  while  (after 
scrubbing  and  rinsing  them)  be- 
fore commencing  the  operation, 
and  into  which  he  can  frequently 
plunge  them  during  the  course 
of  the  performance,  should  be 
provided  and  placed  within  a 
convenient  distance. 

The    Clean    Aseptic    Towels 
and  Sheets. — An  abundance  of  clean  aseptic  towels  and  sheets  is  required 
not  only  for  the  purpose  of  securing  general  cleanliness  of  the  patient's 
immediate  surroundings,  but  also  for  properly  protecting  and  isolating  the 


Fig.  66. — Markoe's  operating  table. 


58 


OPERATIVE   SURGERY. 


field  of  operation.  When  used  for  the  latter  purpose  they  should  be  made 
aseptic  by  sterilization  with  moist  heat,  or  antiseptic  by  long  saturation 
with  effective  fluids  of  this  nature. 


During  an  operation  the  surgeon  frequently  needs  to  wipe  his  hands 
or  the  immediate  surrounding  surface  of  the  seat  of  the  procedure ;  for  this 
purpose  wet  antiseptic  towels  are  the  better,  as  dry  ones  do  not  so  readily 
clean  the  surface,  and  they  are  applied  with  less  ease  and  are  more  liable 
to  convey  infection.     A  dozen  each  of  dry  steam  sterilized,  and  a  similar 


Fig.  68. — Pryor's  portable  table,  folded. 

number  of  wet  antiseptic  ones,  should  be  provided  in  advance  of  the  op- 
eration and  kept  in  separate  bundles,  carefully  wrapped  in  wet  antiseptic 
towels  or  antiseptic  gauze  arranged  for  the  purpose,  or  inclosed  in  sterilized 
receptacles  and  withdrawn  as  needed.  The  textile  fabrics  used  in  contact 
with  the  field  of  operation  or  with  the  instruments  and  the  hands  of  the 
operator  must  be  carefully  prepared  and  handled,  and  frequently  changed, 
otherwise  they  may  become  potent  agents  of  wound  infection. 


THE   GENERAL  CONSIDERATIONS. 


69 


The  Aseptic  and  Antiseptic  Sohit ions. —Much,  has  been  said  and  written 
recrarding  these  agents.     To  the  watery  solutions  of  carbolic  acid  and  cor- 


FiG.  69.— Edebohl's  portable  table. 


Fig.  70. 

Edebohl's  table,  folded. 


rosive  sublimate  have  been  given  the  greatest  attention  and  use.     The  ease 
of  their  procurement  and  the  general  belief  in  their  greater  comparative 


Fig.  71. 

Krug's  portable  inclined  plane. 

efficiency  account  reasonably  for  the  merited  discrimination.     Antiseptic 
solutions  are  employed  by  some  with  a  degree  of  superficial  dispatch  indica- 


60  OPEEATIYE  SURGERY. 

tive  of  unwise  confidence  in  their  efficiency,  and  by  others  with  an  assiduity 
and  faith  comparable  to  the  zeal  of  a  fanatic. 

Antisejitic  fluids  were  once  used  in  everything  that  had  to  do  with  the 
wound,  and  also  to  the  fresh  surfaces  of  the  wound  itself,  at  intervals,  or 
continuously  during  an  operation,  by  means  of  the  spray,  douche,  and  spong- 
ing.    However,  it  soon  appeared  that  the  free  use 
of  these  fluids  not  only  hindered  repair,  but  also 
was  a  source  of  discomfort  to  the  patient  and  the 
cause  of  annoyance  and  delay  to  the  surgeon.     A 
little  later  the  discovery  of  the  facts  that  pus-pro- 
ducing germs  could  withstand  for  an  hour  or  so 
Fig.  72. — Laving  basin.       without  destruction  the  direct  action  of  stronger 
solutions  of  corrosive  sublimate  than  can  be  wisely 
employed  in  surgery,  and  that  these  germs  can  be  wiped  from  the  surface 
of  wounds  after  thorough  douching  with  these  fluids,  led  to  the  belief  that 
their  use  in  this  manner  can  be  wisely  omitted  from  the  technique  of  fresh 
wound  treatment. 

Antiseptic  solutions  should  be  used  in  lieu  of  the  aseptic  by  all  who  are 
obliged  to  handle  the  instruments,  the  undressed  wound  or  anything  com- 
ing in  contact  with  it. 

Carholic  acid  is  frequently  employed ;  it  is  cheap,  easily  obtained,  and  in 
a  strong  solution  is  very  efficient.  Two  solutions  are  commonly  used,  a 
weak  and  a  strong  solution.     The  latter  is  made  as  follows : 

Carbolic-acid  crystals 1  part. 

Alcohol 1     " 

Water 20  parts. 

This  solution  may  be  employed  for  washing  the  surfaces  before  opera- 
tion, for  immersion  of  the  instruments,  and  for  the  spray  when  desired.  The 
cleansing  of  the  hands  with  this  solution  should  be  avoided,  as  it  constringes 
the  integument,  benumbs  the  sensibility,  and  is  often  followed  by  exfoliation 
of  the  cuticle. 

The  weaker  solution  is  employed  for  the  general  purposes  of  cleanliness, 
and  can  be  freely  used  in  securing  this  end,  but  is  altogether  too  weak  to 
meet  the  special  requirements  of  antisepsis.  The  following  is  the  composi- 
tion : 

Carbolic-acid  crystals 1  part. 

Alcohol 1     " 

Water 40  parts. 

Carbolic  acid  is  often  combined  with  oleaginous  substances  in  the  pro- 
portion of  one  of  the  acid  to  five  or  ten  of  the  substance,  and  although  the 
antiseptic  power  of  the  acid  is  lessened,  it  is  not  entirely  overcome,  by  such 
combinations.  The  objections  to  carbolic  acid  are  its  offensive  odor  and  the 
liability  to  produce  poisoning.  The  former  objection  can  be  tolerated,  while 
the  latter  can  be  prevented  in  nearly  all  instances  by  not  permitting  the 
strong  solution  to  become  confined  within  the  tissues. 

Solutions  of  the  chloride  of  zinc  (1  to  15),  iodine  (1  to  500),  sulphocarbo- 
late  of  zinc  (1  to  80),  bichloride  of  mercury  (1  to  2,000  to  1  to  1Q,000),  binio- 


THE   GENERAL   CONSIDERATIONS.  61 

dide  of  mercury  (1  to  2,000),  a  saturated  solution  of  boric  acid,  sulphur- 
ous acid,  pure  or  diluted  (1  to  2),  or  a  saturated  solution  of  iodoform  and 
ether,  etc.,  are  variously  employed  as  washes  or  applications  to  wounded 
surfaces. 

The  solutions  of  the  bichloride  of  mercury  (1  to  2,000  to  1  to  10,000)  are 
deserving  of  especial  consideration,  inasmuch  as  they  rival  the  carbolic-acid 
solutions  as  antiseptic  agents.  Like  the  former,  they  are  cheap,  accessible, 
efficient,  and  of  little  danger  ;  unlike  them,  they  are  inoffensive,  more  active, 
less  penetrating,  but  do  not  benumb  the  sensations  of  the  operator.  They 
should  be  freshly  prepared  before  using,  and  their  tendency  to  chemical 
transformation  into  the  chloride  by  exposure  counteracted  by  the  addition 
of  a  small  amount  of  common  salt.  The  liability  of  mercurial  poisoning 
from  a  proper  use  during  an  operation  is  of  little  practical  importance.  It 
is  not  advisable,  however,  to  employ  these  solutions  for  the  purpose  of  the 
daily  cleansing  of  wounds  of  larger  size,  since  thus  the  constitutional  effects 
may  be  produced.  For  the  purpose  of  cleansing  large  cavities  they  should 
not  be  used  oftener  than  twice  a  week,  and.  should  be  carefully  drained 
from  the  wound  cavity,  and  the  patient  be  rigidly  scrutinized  to  detect  the 
first  manifestation  of  the  constitutional  effects  of  mercury. 

Beta-napMhol  is  used  for  the  same  purpose  as  the  bichloride  of  mercury 
in  a  solution  of  1  to  2,500  or  3,000,  but  is  less  active.  Later,  kreolin  (in 
a  five-per-cent  emulsion)  is  safely  used  to  irrigate  large  cavities,  as  it  has  no 
toxic  effect. 

Thierscli's  Fluid. — Thiersch's  fluid,  composed  of  one  grain  of  salicylic 
acid  and  six  grains  of  boric  acid  to  an  ounce  of  water,  is  frequently  em- 
ployed for  antiseptic  purposes.  This  solution  is  bland,  and  does  not  pro- 
duce the  catheretic  influence  upon  the  tissues  that  is  so  characteristic  of 
the  strong  carbolic  and  bichloride-of-mercury  solutions.  Thiersch's  fluid 
may  be  used  in  operations  on  serous  surfaces,  and  on  the  mucous  mem- 
brane of  the  eye,  throat,  and  urethra.  It  can  be  employed  with  safety  at 
all  times,  and  the  use  is  especially  indicated  when  idiosyncrasy  or  extreme 
youth  of  the  patients  contra-indicate  the  employment  of  the  standard  solu- 
tions of  carbolic  acid  and  mercury.  Convenience  of  use  is  facilitated  by 
increasing  the  comparative  amount  of  the  substances  to  conform  to  a  pint 
of  water.  The  powders  thus  compounded  and  securely  inclosed  can  be  kept 
constantly  at  hand  and  ready  for  immediate  use. 

Peroxide  of  Hydrogen. — Peroxide  of  hydrogen  has  long  been  recognized 
as  a  strong  deoxidizing  agent.  It  can  be  used  for  antiseptic  purposes  in  the 
original  strength,  or  diluted  with  water  to  various  strengths,  depending  on 
the  indications  for  employment.  It  is  used  at  full  strength  in  the  treat- 
ment of  old  sinuses  and  abscess  cavities  ;  in  solutions  of  twenty-five  per  cent 
it  is  poured  or  injected  into  open  cavities,  whether  recent  or  long-established, 
for  cleansing  purposes.  It  is  sometimes  employed  in  abdominal  surgery, 
especially  if  septic  influences  be  present,  and  often  in  the  surgery  of  mu- 
cous surfaces.  The  prompt  and  decided  effervescence  of  solutions  of  this 
fluid  is  regarded  as  advantageous  in  dislodging  and  bringing  to  the  surface 
the  septic  and  diseased  products  that  lie  loosely  and  often  unsuspectedly  in 


Q2  OPERATIVE  SURGERY. 

the  depths  of  operation  wounds,  well-opened  peritoneal  interstices,  and  old 
sinuses.  If  free  escape  be  not  afforded  forced  dissemination  of  infecting 
agents  may  occur.     Ordinary  solutions  are  not  germicidal. 

This  fluid  is  not  advised  in  delicate  operations,  as  the  effervescent  char- 
acter obscures  the  field,  and  may  otherwise  annoy  the  operator. 

Heat  is  the  most  valuable  and  available  antiseptic,  moist  heat  is  more 
efficient  than  dry.  Pressure  increases  the  potency  of  the  latter.  All  patho- 
genic bacteria  are  destroyed  at  140°  F.  for  ten  minutes,  except  tubercle 
bacillus  and  anthrax  spores,  requiring  212°  F.,  moist,  for  four  minutes. 

Solution  of  Carbonate  of  Soda. — The  carbonate-of-soda  solution  is  espe- 
cially adapted  to  the  purification  of  surgical  instruments.  When  boiled 
for  fifteen  or  twenty  minutes  in  a  ten-per-cent  aqueous  solution  of  ordinary 
washing  soda,  they  are  properly  purified  for  surgical  purposes.  This  act 
exercises  a  minimum  degree  of  impairment  of  the  cutting  edge  and  lessens 
rusting.  However,  the  organic  parts  of  instruments  are  more  or  less  im- 
paired by  its  influence. 

Boiled  Water. — Boiled  water  is  an  excellent  aseptic  fluid,  and  can  be 
emplo3'ed  in  connection  with  surfaces  and  substances  that  are  properly 
purifled  alread3^  If  one  could  be  assured  of  immunity  from  infecting 
agents,  this  fluid  would  be  an  ideal  one  for  local  use,  as  it  is  bland  and 
unirritating,  and  can  be  readily  and  bounteously  provided  wherever  re- 
quired. It  is  an  excellent  and  almost  universal  menstruum  for  antiseptic 
solutions. 

Saline  Solution. — The  saline  solution  is  made  by  dissolving  in  a  quart 
of  filtered  water  sterilized  at  240°  F.  a  drachm  and  a  half  of  table  salt.  On 
account  of  its  unirritating  nature,  it  is  used  chiefly  at  a  temperature  of 
100°  to  110°  F.  for  the  cleansing  of  serous  surfaces.  At  the  present  time  it 
is  commonly  employed  in  the  treatment  of  shock,  especially  when  due  to 
loss  of  blood  (page  220  et  seq.). 

Alcohol,  thymol,  eucalyptol,  and  the  essential  oils,  especially  of  mustard, 
are  recommended  for  use  not  infrequently  on  account  of  their  antiseptic 
virtues. 

The  Sponges. — Sponges  act  more  promptly  than  any  other  agent  that 
can  be  employed  for  the  purpose  of  wiping  and  absorbing  from  the  surface 
of  a  wound  the  blood  and  other  fluids  that  attend  an  operation.  And  this 
is  especially  true  if  the  hsemorrhage  be  profuse,  or  rapid  absorption  of  the 
blood  and  fluids  be  required.  They  are,  however,  often  the  cause  of  infec- 
tion of  a  wound  owing  to  careless  handling,  imperfect  preparation,  and 
subsequent  care,  and  for  these  reasons  their  use  is  discarded  by  many. 

The  surgeon  should  guard  against  the  former  means  of  infection  by  re- 
stricting the  handling  of  sponges  to  as  few  assistants  as  possible,  and  per- 
mitting those  only  to  touch  them  who  are  well  informed  and  appreciative 
of  the  importance  of  the  trust  reposed  in  them.  The  rinsing  and  hand- 
ling of  sponges  by  careless,  uninformed,  and  indifferent  attendants  is  a  com- 
mon source  of  danger  that  can  not  be  overestimated.  The  variety  known 
as  "surgeons'  sponges"  are  the  most  expensive  in  use.  The  less  costly  larger 
sponges  of  a  proper  texture  can  be  cut  into  portions  of  suitable  size,  and 


THE  GENERAL  CONSIDERATIONS. 


P.3 


when  thoi'uiighly  clciuiscd  and  disinrocled  can  be  cinjiloycd  with  satisfac- 
tory results.  No  sponge  oi'  whatever  quality  should  be  used  until  it  has  been 
freed  of  all  foreign  matters  and  properly  disinfected.  It  should  be  the  prac- 
tice to  select  and  cleanse  a  number  of  sponges  and  keep  them  in  a  closed 
jar  containing  a  strong  solution  of  carbolic  acid  or  other  suitable  disinfec- 
tant until  needed.  The  broad,  thin  sponges  for  abdominal  work  should  be 
at  hand  and  prepared  for  instant  use.  Aseptic  gauze  pads  of  generous  size 
and  with  tape  attachments  are  now  much  more  often  employed  in  abdom- 
inal surgery  than  the  broad  sponge. 

Sponges  ought  not  to  be  used  repeatedly.  It  is  better  evidence  of  care- 
ful surgery  to  provide  fresh  ones  in  each  case  than  to  use  them  a  second 
time,  even  under  seemingly  favorable  circumstances. 

'  The  Preparation  of  Sponges. — Various  methods  are  advised  for  this 
purpose,  the  following  (Schimmelbusch)  is  both  simple  and  effective.  The 
sponges  are  beaten,  washed,  and  kneaded  repeatedly  in  cold  and  warm  water, 
until  the  dirt,  shells,  and  other 
foreign  matter  are  entirely  re- 
moved; they  are  then  pressed 
together,  surrounded  by  gauze, 
and  put  into  a  one-per-cent 
aqueous  solution  of  soda,  just 
removed  while  boiling  from 
the  fire,  in  which  they  remain 
half  an  hour.  Sponges 
should  not  be  boiled  as  boil- 
ing hardens  them.  The  soda  is 
now  washed  away  with  boiled 
water,  after  which  they  are 
stored  in  a  tight  jar  filled 
with  a  solution  (1  to  3,000) 
of  corrosive  sublimate. 

The  "  Wipers:'  "  Tup- 
fers,"  and  "Pads." — Wipers 
(Fig.  73)  are  made  of  steril- 
ized gauze  folded  upon  itself 
in  such  a  manner  as  to  form 
squares  of  various  sizes  and 
thickness,  dependent  on  the 
requirements  of  a  special 
case.  The  cut  edges  of  the 
gauze  are  turned  in  and 
stitched  in  place,  so  that  loose 

threads  will  not  become  detached  and  remain  in  the  wound.  Ordinarily 
wipers  are  made  two  and  a  half  to  three  inches  square,  and  comprise  four 
or  five  thicknesses  of  the  gauze. 

Before  using,  they  are  thoroughly  sterilized  by  exposure  to  steam  for 
half  an  hour  at  least  while  wrapped  loosely  in  a  towel  or  inclosed  in  steril- 


FiG.  73. 


1,  Aseptic  gauze  pad.    3,  Aseptic  wiper. 
3,  Aseptic  tupfer. 


64  OPERATIVE  SURGERY. 

izing  cases.  When  in  use  they  should  be  placed  close  to  the  surgeon  or 
his  first  assistant,  who  should  pick  them  up,  use  them,  and  throw  them 
aside  at  once;  thus  the  danger  from  miscellaneous  handling  and  repeated 
use  are  certainly  avoided.  Wipers  and  pads  can  not  be  so  well  employed  in 
deep  or  serous  cavities  as  in  other  situations,  since  they  can  not  be  so  effec- 
tually applied,  and  they  may  be  overlooked  and  left  behind,  unless  a  piece 
of  tape  of  suitable  length  be  connected  with  each  and  left  in  view  anchored, 
if  need  be,  by  a  forcipressure  (Fig.  73).  Scrupulous  care  should  be  taken 
to  remove  loosened  threads  from  these  agents,  else  they  may  be  left  behind 
in  the  wound  and  hinder  healing  by  their  presence,  especially  if  they  become 
finally  infected. 

Not  a  less  number  than  twenty  or  thirty  wipers  should  be  provided  for 
an  operation  of  ordinary  magnitude.  The  prompt  removal  of  blood  from 
a  wound  is  better  attained  by  sponges  than  by  wipers  or  tupfers.  The 
latter  absorb  less  readily,  and  are  less  well  adapted  for  the  use  of  holders. 

Tupfers  are  small  balls  of  sterilized  cotton  surrounded  by  absorbent 
gauze  (Fig.  73).  Like  the  wipers,  they  are  made  of  various  sizes  and  for 
special  purposes ;  they  are  prepared  for  use  in  the  same  way,  employed  for 
the  same  purpose,  and  are  then  thrown  away. 


CHAPTER  11. 

AGENTS  FOR   THE  CONTROL   OF  HEMORRHAGE. 

The  agents  tliat  are  employed  to  arrest  haemorrhage  are  multifarious 
and  suited  to  all  of  its  phases.  They  may  be  divided  into  the  natural 
and  artificial  haemostatics,  and  the  former  may  be  subdivided  into  the  iem- 
forary  and  permanent  varieties. 

A  natural  hcemostatic  is  one  interposed  by  Nature — one  which  arises 
as  a  natural  consequence  from  stimulation  of  the  peculiar  inherent  tenden- 
cies of  the  blood  and  the  vessels  by  traumatic  influence.  The  jDrincipal 
temporary  natural  agents  or  hsemostatics  are  the  contraction  and  retraction 
of  the  inner  coats  of  a  divided  or  tightly  ligatured  vessel,  followed  by  the 
formation  of  a  blood  clot  within  the  vessel  and  between  it  and  the  con- 
tiguous tissues.  Proper  contraction  and  retraction  of  the  coats  of  a  vessel 
require  that  these  coats  be  not  diseased,  and  that  they  be  completely  severed 
by  the  ligature  or  other  constricting  force.  However,  the  internal  clot  is 
formed  with  a  practical  certainty  whether  these  coats  be  closely  constricted 
or  completely  divided  by  the  ligature.  This  fact  is  of  great  importance  in 
connection  with  vessels  so  extensively  diseased  that  the  severance  of  the 
inner  coats  by  the  ligature  may  lay  the  foundation  for  secondary  haem- 
orrhage. 

The  formation  of  a  proper  internal  clot  requires  that  a  suitable  distance 
be  present  between  the  ligature  and  the  collateral  branches;  also  that  the 
blood  and  the  coats  of  the  vessel  be  in  a  healthy  state.  The  recognition  of 
the  foregoing  facts  is  of  great  importance  in  determining  the  site  and  the 
feasibility  of  an  operation. 

The  permanent  natural  agent  in  the  arrest  of  haemorrhage  is  the  con- 
traction, permanent  organization  of  the  blood  clots,  and  union  with  the  wall 
of  the  vessel,  causing  thereby  a  complete  occlusion  of  its  lumen.  This  result 
will  depend  largely  upon  the  healthy  condition  of  the  coats  of  the  vessel  and 
of  the  blood,  and  it  has  a  very  important  bearing  on  the  possibility  of  the 
occurrence  of  that  much-dreaded  sequel  of  an  operation — secondary  h'jm- 
orrhage. 

The  Artificial  Hsemostatics. — The  artificial  hcPmostatics  are  temporary 
in  character,  and  should  be  supplemented  by  the  natural  to  effect  a  per- 
manent closure  of  the  vessel.  The  following  are  the  latest,  and  also  the 
ones  long  in  constant  use:  Gelatin,  animal  extracts,  etc.,  st^'ptics,  posture 
of  injured  part,  bandages  of  various  kinds,  digital,  instrumental,  and 
elastic  pressure,  pressure  by  a  simple  or  graduated  compress,  acupressure, 

65 


66  OPERATIVE  SURGERY. 

torsion,  forceps,  serre-lines,  cautery,  etc. ;  finally,  and  the  most  practical, 
the  ligature. 

Eecently  a  number  of  remedies  exercising  influence  in  arresting  haem- 
orrhage by  modifying  the  normal  constituents  of  the  blood  have  been 
brought  to  the  notice  of  the  profession.  Gelatin,  supra-renal  extract, 
adrenalin,  and  calcium  chlorid  are  prominent  examples. 

Gelatin. — The  injection  of  a  normal  salt  solution  of  gelatin  into  the 
subcutaneous  tissue  increases  the  coagulability  of  the  blood.  When  taken 
by  the  mouth  the  coagulating  property  is  much  diminished,  but  not  en- 
tirely destroyed.  It  appears  to  exercise  a  controlling  influence  when  applied 
to  a  bleeding  surface.  The  use  by  rectum  is  commended  by  some,  but  can 
not  be  regarded  equal  to  injection  into  the  tissue.  It  seems  best  employed 
in  connection  with  the  normal  saline  solution  forming  Carnot's  solution. 
This  solution,  when  prepared  after  Sailer's  method,*  offers  an  approved 
plan  of  administration.  Take  of  pure  common  salt  75  grains  (15  gms.), 
of  distilled  water  1  quart  (1  liter),  of  gelatin  3  ounces  (100  gms.).  Heat 
the  water  to  212°  F.  (100°  C),  and  slowly  stir  in  the  gelatin  to  form  a 
solution.  Cool  the  solution  to  104°  F.  (40°  C),  add  the  white  of  an  egg, 
stir  for  several  minutes,  then  boil  the  mixture.  Filter  the  product  through 
gauze  and  then  through  paper.  Pour  the  fluid  into  test-tubes,  each  con- 
taining 2^  drams  (10  cc),  plugging  the  open  ends  with  cotton.  Sterilize 
the  tubes  in  a  steam  sterilizer  for  fifteen  minutes  for  each  of  three  con- 
secutive days.  Before  using  liquefy  the  gelatin  by  placing  the  tube  in  a 
cup  of  hot  water ;  pour  the  fluid  into  a  sterile  glass,  from  which  it  is  drawn 
into  a  sterile  syringe. 

The  Precautions. — Avoid  injecting  the  solution  into  a  blood-vessel.  Be 
sure  that  it  is  sterile,  because  of  the  liability  of  tetanus  from  its  use.  Irre- 
spective of  the  menace  of  tetanus  the  use  is  not  without  danger,  as  deaths 
from  other  causes  have  occurred.  It  should  not  be  employed  in  cases  with 
renal  disease,  as  it  irritates  the  kidneys.  From  2^  to  5  drams  of  a  ten-per- 
cent solution  may  be  injected  at  a  time.  It  may  be  introduced  into  the 
subcutaneous  tissue  either  at  the  outer  side  of  the  thigh,  between  the 
shoulders,  or  beneath  the  breast  in  the  female.  It  should  be  given  at 
the  temperature  of  the  body,  and  as  frequently  as  the  character  of  the  case 
demands. 

Supra-Renal  Extract. — This  substance  is  a  valuable  agent  for  the  con- 
trol of  capillary  oozing,  and  is  especially  applicable  to  operations  on  the 
larynx,  pharynx,  nose,  etc. ;  also  for  checking  hemorrhage  from  hollow 
viscera.  It  is  not  impaired  by  boiling,  and  is  preserved  by  the  addition 
of  carbolic  acid.  It  acts  promptly  (tAventy  seconds)  and  decidedly  (five 
minutes),  its  effects  last  from  one  and  a  half  to  twenty-four  hours  (Som- 
ers).  Coleman  commends  the  giving  of  5  grains  of  adrenal  substance 
every  hour  in  the  intestinal  hasmorrhage  of  typhoid  fever.  It  may  be  given 
in  10-grain  doses  by  the  bowel  when  use  by  the  mouth  causes  nausea. 

Adrc7iaUn  Chlorid  is  derived  from  the  gland  and  its  extracts,  being  625 

*  Therapeutic  Gazette,  August,  1901. 


AGENTS  FOR  THE  CONTROL  OP  HiEMORRHAGE.         67 

to  1,000  times  stronger  than  the  former,  and  easily  sterilized  by  heat.  It 
is  employed  locally  and  administered  internally.  Internally,  i.  e.,  intra- 
venously, intraperitoneally,  subcutaneously,  and  by  the  mouth.  Locally  in 
normal  saline  solution  1  to  1,000  to  10,000.  Applied  directly  or  sprayed 
on  the  surface  of  mucous  membranes  it  acts  admirably,  controlling  capil- 
lary bleeding  during  and  after  operation. 

Intravenously. — Langworth  commends  this  method  of  employment  in 
eases  of  sudden  heart  failure  in  from  y^  to  -^^^-q  of  a  grain,  conjoined 
with  a  copious  saline  solution.  Crile  *  declares  that  adrenalin  acts  upon 
the  heart  and  blood-vessels,"  and  demonstrates  its  great  use  in  profound 
shock,  employed  in  the  proportion  of  1  to  50,000  to  100,000  of  the  saline 
solution. 

Intraperitoneally  it  is  used  for  the  same  purpose  and  in  the  same  man- 
ner as  when  employed  upon  mucous  surfaces. 

Subcutaneously. — Adrenalin  chlorid  may  be  administered  subcuta- 
neously in  the  proportion  of  yro  of  a  grain  to  a  pint  of  saline  solution. 
By  the  mouth  in  doses  of  y-^  to  ^j  gr.  in  solution  or  in  tablet  three  times 
daily.  Comparatively  little  practical  utility  attends  administration  by 
mouth  or  rectum.  Since  adrenalin  seems  to  impair  the  germicidal  power 
of  the  blood,  it  should  be  given  with  great  caution  in  cases  of  infection. 
The  introduction  of  the  drug  should  be  slowly  made,  occupying  half  an 
hour  or  so.  The  treatment  repeated  with  increasing  doses  until  response 
is  seen  or  failure  is  apparent. 

"  The  toxic  dose  for  men  is  not  known,  but  it  is  probably  several  hun- 
dred times  greater  than  that  in  which  the  drug  is  ordinarily  given."  f 

Calcium  Chlorid. — In  hasmophilia  the  use  of  this  drug  in  10-grain 
doses  three  times  a  day,  for  a  week  or  so,  as  a  preparatory  measure  of 
operation  appears  to  be  of  considerable  importance  in  controlling  the 
loss  of  blood  that  so  often  characterizes  even  trivial  operations  in  these 
cases.  In  a  similar  manner  it  may  be  given  before  and  after  operations 
associated  with  cholsemia,  but  it  does  not  appear  to  exercise  a  sufficient 
influence  on  the  profounder  cases  to  justify  the  placing  of  a  special  reli- 
ance upon  its  virtues  in  these  instances.  In  the  lighter  forms  it  may  be  of 
some  special  value.  It  should  be  recalled  that  in  the  giving  of  this  drug 
for  a  long  time,  or  in  doses  of  unusual  size,  instances  of  thrombosis,  with- 
out other  apparent  causes,  have  happened,  giving  rise  to  the  notion  that  in 
some  cases  at  least  a  dangerous  degree  of  coagulability  may  be  caused  which 
of  itself  alone  might  outrank  in  significance  the  reasons  for  moderation. 
Wright,  who  first  suggested  its  use,  pointed  out  the  fact  that  if  given  too 
freely  or  for  longer  periods  than  three  or  four  days  diminished  coagula- 
bility might  follow.  Evidently  further  light  is  needed  in  this  regard.  The 
comparative  coagulation  time  of  the  blood,  taken  before  and  after  its 
employment,  is  a  guide  by  which  the  efficiency  of  the  drug  may  be 
estimated. 


*  The  Boston  Medical  and  Surgical  Journal,  March  5th,  1903. 

f  American  Med.,  page  813,  November,  1903  (Martin  and  Pennington). 

7 


68  OPERATIVE  SURGERY. 

The  Styptics. —  Cold  and  hot  water  are  employed  to  check  oozing  of 
blood,  even  if  the  bleeding  be  of  an  active  type.  Formerly  the  cold  was 
used  exclusively,  and  the  suggestion  of  the  use  of  hot  water  for  this  pur- 
pose, except  in  greatly  depressed  subjects,  caused  ominous  frowns  to  gather 
on  the  brows  of  experienced  practitioners.  Once,  within  the  easy  recollec- 
tion of  the  writer,  a  celebrated  obstetrician  vetoed  the  graduation  of  a 
student  who  ventured  to  express  the  then  somewhat  premature  opinion  that 
intra-uterine  injections  of  hot  water  were  a  suitable  treatment  for  post- 
partum haemorrhage.  Latterly,  however,  the  use  of  hot  water  for  the  arrest 
of  hsemorrhages  has  almost  entirely  superseded  the  cold.  If  water  as  hot  as 
the  hand  can  well  bear  (118°  F.)  be  freely  applied  to  a  cut  surface,  it  not 
only  acts  as  a  hsemostatic  but  also  exercises  an  aseptic  effect  on  the  tissues. 
If  a  large  sponge  saturated  with  hot  water  be  pressed  against  an  oozing  sur- 
face, the  styptic  effect  is  usually  prompt  and  salutary. 

Solutions  of  subsulphate  of  iron,  alum,  tannin,  and  resin,  etc.,  were 
much  more  frequently  applied  to  bleeding  surfaces  formerly  than  at  pres- 
ent. The  inorganic  styptics  can  be  applied  directly  or  in  aqueous  solutions 
of  various  strengths ;  the  organic  ones  are  usually  liquefied  in  ether,  alcohol, 
or  chloroform  and  then  applied.  The  employment  of  these  agents  for  the 
arrest  of  haemorrhage  from  a  wound  is  not  to  be  countenanced  until  all  other 
means  have  proved  futile.  Their  inconsiderate  introduction  into  a  wound 
disguises  the  presence  of  foreign  bodies,  renders  cleansing  imperfect,  and 
destroys  the  possibility  of  prompt  union.     Collodion,  when  dissolved  in  ether 

and  applied  to  the  already  united  lips  of 
a  wound  by  means  of  a  camel's-hair  pen- 
cil, not  only  controls  oozing  but  aids  pri- 
mary union  by  causing  closer  coaptation 
of  the  wound  borders  and  the  exclusion  of 
infecting  agents.  Styptic  collodion  with 
or  without  a  small  amount  of  iodoform  in 
the  solution  is  better,  possibly,  than  the 
plain  collodion  for  the  purpose. 
/,  The  Position. — The  elevation  or  flex- 

ion of  a  limb  (Fig.  74)  impedes  its  circu- 
*tPtt      :::^    W,:  „  ktlou,  espcclally  that  of  the  more  distant 

portions  of  the  body,  and  therefore  cor- 
respondingly lessens  the  degree  of  haemor- 
rhage of  these  parts.     The  reverse  of  this 
EiG.  74— Forced  flexion  of  the  knee     principle  counsels  the  lowering  of  the  head 
for  temporary  arrest  of  hsemor-      •  ^   ,  i  ,  •      ,    t  i     ,    -,    r  n      i 

rhage  in  the  popliteal  space.  "  the  patient  be  prostrated  from  the  loss 

of  blood. 
The  Bandages. — The  bandages  can  be  divided  into  two  distinct  classes, 
the  inelastic  and  elastic.  The  inelastic  variety.,  the  ordinary  roller  bandage, 
is  well  adapted  for  the  arrest  of  capillary  and  venous  oozing  when  applied 
firmly  to  the  bleeding  part.  Under  these  circumstances  the  interposition 
of  an  abundant  amount  of  gauze  or  absorbent  cotton  equalizes  the  pressure 
of  the  bandage  and  adds  correspondingly  to  the  comfort  of  the  patient. 


AGENTS  FOR  THE  CONTROL  OP  HJEMORRHAGE. 


69 


The  elastic  bandage,  of  which  Esmarcli    is    tlie   inventor,  is   composed 
of  elastic  webbing  of  the  Avidth  of   an    ordinary  roller,  and  of   sufficient 


,-«.-    '\*r\r'\\iWMMm!!iim7^^ 


Fig.  76. 

Elastic  bandage 

applied. 


Fig.  75. — Elastic  bandage. 

length  to  meet  the  requirements  (Fig.  75).  It  is  ap- 
plied firmly  to  the  limb  in  a  spiral  manner  from  the 
distal  extremity  (Fig.  76)  to  a  good  distance  above  the 
point  of  operation,  and  then  it  is  supplemented  by  a 
rubber  cord  or  strap  passed  firmly  around  the 
limb  at  this  point  held  by  forceps,  a  clasp,  or 
hook  adapted  to  that  special  purpose  (Figs. 
77,  78,  and  79).  The  bandage  is  then  re- 
moved by  unwinding  it  from  above  down- 
ward. The  clamp  devised  by  Langenbeck  (Fig.  80)  can  be  ap- 
plied to  the  upper  turns,  or  they 


can  be  fastened  together  by  a  piece 
of  an  ordinary  roller  tied  tightly 
around  them,  after  which  the  elas- 
tic bandage  is  removed  from  below 
upward.  After  the  removal  of  the 
bandage  the  limb  will  have  a  cadav- 
erous aspect,  being  entirely  devoid 
of  blood,  and  the  necessary  opera- 
tion can  be  performed  and  the 
wound  dressed  without  the  least 
haemorrhage.  However,  this,  like 
many  other  useful  ones,  has  objec- 
tionable features.  The  removal  of 
the  bandage  and  the  cord  is  often 
followed  by  a  vigorous  and  persist- 
ent oozing ;  its  application  may 
force  into  the  circulation  deleteri- 
ous agents  which  form  the  basis  of 
septic  or  other  disease.  Its  use  may 
temporarily  paralj'ze  the  part  to 
which  it  was  applied^  and  cause 


Fig.  77. — Nicaise's  compression  band. 


70 


OPERATIVE  SURGERY. 


transient  disturbances  of  the  general  circulation.  These  latter  are  not,  how- 
ever, sufficiently  important  to  contra-indicate  its  employment.  In  amputa- 
tion of  an  extremity  for 'gangrene  due  to  diseased  vessels,  the  elastic  bandage 

should  not  be  applied,  since  the 
pressure  will  crush  the  stiffened 
capillaries  and  otherwise  impair 
the  nutrition  of  the  limb.  Digi- 
tal pressure  of  the  vessel  only 
should  be  employed  in  these 
cases.  The  tendency  to  severe 
oozing  is  an  objection  which 
must  stand  against  the  use  of 
this  agent  ;  but  its  power  to 
force  improper  products  from 
diseased  or  injured  parts  into 
the  general  circulation  can  be 
obviated  by  omitting  the  appli- 
cation to  those  parts  —  that  is, 
by  raising  the  limb  and  holdiug 
it  till  well  depleted  by  the  force 
of  gravity,  then  applying  the 
bandage  to  the  sound  parts, 
below  the  seat  of  injury  or  disease,  and  passing  very  lightly 
over  or  omitting  altogether  these  parts  on  the  way  up  to  the 
seat  of  operation,  and  then  using  the  rubber  band  as  before. 
It  is  adapted  to  the  accomplishment  of  another  very  impor- 
tant  purpose — that  of  forcing  the  blood  of  the  extremities 

into  the  circulation  of 
the  trunk  in  cases  of  ex- 
treme prostration  from 
hemorrhage.    Martinis 

handage  (Fig.  81)  is  sim- 
ply a  rubber  roller,  and  is 
used  to  meet  the  same  in- 
dications as  the  former. 
It  can  be,  however,  more 
readily  cleansed  than  the 
webbed  one,  and  in  this 
particular  is  preferable  to 
of   a   suitable   size   to  pass 


Fig.  78.- 


-Foulis"s  fastening  in 
position. 


Pig.  79. 
Foulis's  fasten- 
ing with  rub- 
ber cord. 


Fig.  80. — Langenbeck's  clamp. 


Solid 


Fig.  81. — Martin's  bandage. 


ruhher  rings 

over  an  extremity  have  been  used  as  a  substi- 

the  rubber  roller.     In  connection  with  the 

digits,  and  even  the  foot,  hand,  and  wrist, 

they  act  quite  well,  but  have  not  as  yet 

entered  into  common  use. 

The  Compresses. — Two  kinds  of  com- 
presses are  in  common  use :  the  simple 


AGENTS  FOR  THE  CONTROL   OP  HEMORRHAGE. 


71 


and  graduated.  The  sim])le  cojnjjress  consists  of  several  thicknesses  of 
cloth,  or  other  suitable  material,  folded  in  small  dimensions  ;  it  is  then 
placed  over  the  vessel,  or  upon  the  part  where  pres- 
sure is  desired,  and 
held  in  position  by 
a  tightly  drawn 
bandage  or  a  broad 
strip  of  adhesive 
plaster.  The  grad- 
uated compress 
may     be     formed 

like  an  inverted  pyramid  or  cone,  or  may  be  oblong 
Its  apex  should  be  firm  and  unyielding,  to  give  an  equal 


Fig.  83.— Pyramidal 
compress. 


Fig.  83. — Oblong  compress. 


(Figs.  82,  83,  84) 
and  constant  pressure. 
This  compress  can  be 
made  of  superimposed 
layers  of  cloth  on  anti- 
septic gauze,  or  other 
suitable  material,  and 
of  a  size  and  shape  to 


^^^^^^^^^^ 


La.iiLAiUiiii.iiiij.t.JA:..G7^~;^.uflUAli;.i.(.L^ 
Fig.  84. — Conical  compress. 


form  a  symmetrical  structure.  It  is  employed  to  make  pressure  upon  the 
deep-seated  vessels  of  soft  parts,  and  to  arrest  haemorrhage  within  a  deep 
wound  or  cavity.  Care  must  be  taken  to  properly  adjust  it,  else  it  may  im- 
pede venous  return,  or  cause  pain  from  pressure  upon  large  nervous  trunks. 

The  Digital  Pressure. 
— Digital  pressure  is  the 
most  available  of  all  the 
compressing  haemostat- 
ics. It  is  constantly  at 
hand,  and  often  intui-' 
tively  seeks  to  arrest  the 
flow  of  blood.  It  is  only 
necessary  to  add  the  in- 
fluence of  a  sensitive  fin- 
ger and  a  sensible  brain 
to  a  knowledge  of  where 
and  how  to  apply  the 
force,  to  render  this  form 
of  pressure  of  inestimable 
value.  The  vessel  should 
be  pressed  against  some 
firmly  resisting  part  lying 
near  it,  as  against  a  bone. 
If  the  bone  be  deeply 
seated,  the  vessel  must  be 
pressed  toward  it  (Fig. 
Fig.  85.— Digital  pressure  on  femoral.  85),  nnless  the  limb  can 


72 


OPERATIVE  SURGERY. 


Fig.  86. — Digital  compression  of  the  brachial  against 
the  bone. 


be  grasped  so  as  to  bring  the  ends  of  the  fingers  against  the  vessel.  If 
blood  flow  from  an  open  wound,  direct  pressure  should  be  made  upon  the 
bleeding  point  with  one  hand,  while  the  other  hastens  to  compress  the  main 
artery  above  the  point  of  haemorrhage.  It  is  not  necessary  to  use  great  force 
to  interrupt  the  blood  current ;  moreover,  to  do  so  tires  the  arm  and  hand, 
and  causes  the  patient  much  pain  ;  use  just  force  enough  to  interrupt  all 

blood  flow.  The  thumb 
of  the  right  hand  is  the 
best  digit  to  apply  at  first ; 
afterward  it  may  be  re- 
lieved in  various  ways  by 
the  alternate  aid  of  the  re- 
maining fingers  (Fig.  86) 
and  thumb  of  the  surgeon 
or  those  of  others  who 
are  present.  If  second- 
ary hemorrhage  be  antici- 
pated, or  have  occurred, 
the  proper  point  for  com- 
pressing the  vessel  in- 
volved must  be  indicated 
by  some  indelible  substance,  so  that  in  case  of  a  sudden  bleeding  an  attend- 
ant can  apply  promptly  the  necessary  pressure.  With  this  object  in  view, 
the  attendants  must  be  instructed  in 
the  details  of  making  the  pressure, 
and  be  thoroughly  acquainted  with 
the  necessity  of  constant  vigilance 
and  of  instant  and  efEective  action. 

The  circulation  of  a  vessel  that  is 
inaccessible  to  proper  digital  com- 
pression, as  the  subclavian,  can  be 
controlled  often  by  the  handle  of  a 
key,  or  by  a  short  crutch,  and  the 
applied  extremity  of  either  should 
be  covered  with  some  soft  material, 
to  prevent  injury  to  the  vessel  and 
the  superimposed  soft  parts. 

The  Instrmnental  Pressure.  — 
Under  this  heading  are  included  the 
various  forms  of  tourniquets  and  such 
other  devices  as  are  not  directly  con- 
nected with  the  adjustment  of  liga- 
tures to  bleeding  vessels.  The  tourni- 
quet commonly  used  was  devised  by  Petit,  and  it  is  no  doubt  familiar  to  all 
(Fig.  87).  It  should  be  cautiously  applied,  with  the  pressure  so  directed  as 
to  crowd  the  vessel  against  the  bone  when  possible  (Figs.  88  and  89).  A 
simple  and  effective  tourniquet  can  be  extemporized  by  placing  a  roller 


Fig.  87. — Petit's  tourniquet. 


AGENTS  FOR  THE   CONTROL   OF   lI.EMORRIIAGE. 


73 


bandage  over  the  site  of  the  vessel  and  confining  it  in  position  by  a  hand- 
kerchief passed  around  the  limb.  If  ihe  handkerchief  be  then  tied  and 
twisted  by  a  stick,  the  circulation  will  be  controlled  (Fig.  90). 


Fig.  88. — Tourniquet  applied  to  femoral. 


Fig.  89. — Tourniquet  applied  to  brachial 


Davyfs  Lever ^  an  implement  devised  by  the  surgeon  whose  name  it  bears, 
was  formerly  often  employed  for  the  especial  purpose  of  controlling  haemor- 
rhage in  amputations  at  the  hip  joint.  The  instrument  is  turned  from 
ebony,    and    is     from 

eighteen      to      twenty  |  f  .  / 

inches  in  length. 
The  surface  is  smooth, 
and  its  extremities 
rounded  ;  its  largest 
diameter  is  about  five 
eighths  of  an  inch.  It 
can  be  graduated  so 
that  the  surgeon  will 
be  able  to  estimate  the 
exact  extent  of  the  en- 
trance into  the  bowel. 
Its  shape  has  been 
variously  modified  to 
meet  the  requirements 
suggested  by  its  more 

extended  use.  It  is  passed  up  the  rectum  in  the  direction  of  that  canal  a 
sufficient  distance  to  make  pressure  on  the  common  iliac  artery  at  the  side 
from  which  the  limb  is  to  be  removed.     The  upper  extremity  of  the  lever  is 


Fig.  90. — Improvised  tourniquet. 


74 


OPERATIVE   SURGERY. 


then  carried  to  the  right  or  left,  as  the  case  may  be,  sujBficiently  to  lie  be- 
tween the  bodies  of  the  lumbar  vertebras  and  the  psoas  magnus  muscle. 
The  lower  extremity  of  the  lever  is  then  raised  so  as  to  bring  the  requisite 
pressure  to  bear  upon  the  vessel  (Fig.  91). 

This  implement  has  been  employed  with  signal  success.     It  can  be  more 
safely  applied  at  the  left  than  at  the  right  side  of  the  body,  because  the  left 


Fig.  91. — Davy's  lever  applied. 

iliac  artery  is  nearer  to  the  rectum  than  is  the  right.  The  introduction 
should  be  preceded  by  an  injection  of  sweet  oil  into  the  rectum,  after  which 
the  lever  is  cautiously  introduced  and  held  in  position  by  a  gentle,  though 
firm,  upward  elevation  of  the  free  end,  thereby  causing  the  perineal  tissues 
to  act  as  a  fulcrum.  The  free  extremity  is  then  pressed  against  the  opposite 
thigh,  and  carefully  held  in  position  during  the  operation.  If  unnecessary 
force  be  used,  the  gut  may  be  torn  or  perforated. 

Trendelenburg'' s  Rod. — Trendelenburg's  rod  is  used  for  the  same  purpose 
as  Davy's  lever,  but  in  an  entirely  different  manner  (Fig.  92).     The  soft 


AGENTS  FOR  THE  CONTROL  OF  HAEMORRHAGE. 


75 


parts  are  transfixed  by  this  rod  at  such  a  depth  as  to  include  the  whole 
thickness  of  the  proposed  flap.  A  strong  rubber  cord  is  then  passed  over 
the  extremities  of  the  rod  with  sufficient  force  to  compress  the  vessels  in  the 
tissues  above  it.  Tlie  flap  can  then  be  made  and  the 
vessels  ligatured  without  loss  of  blood,  after  which  the 
rod  is  withdrawn  and  the  remaining  flap  made  in  a 
similar  manner. 

The  preceding  method  illustrates  the  use  of  trans- 
verse elastic  pressure  as  associated  with  the  transfixion 
of  a  limited  amount  of  the  soft  tissues  by  a  sharp  rod, 
for  the  purpose  of  securing  bloodless  operations. 

Somewhat  recently  Dr.  Wyeth  has  brought  forward 
a  wise  modification  of  this  means,  which  consists  of 
circular  elastic  compression  of  the  entire  limb  associ- 
ated with  pin  or  skewer  transfixion  of  the  soft  parts, 
for  the  same  purpose.  This  method  is  superior  in  all 
respects  to  the  last  two  preceding  ones,  and  which  it 
has  superseded.  Since  the  details  of  the  plan  are  di- 
rected to  amputation  at  the  hip,  their  description  will 
appear  under  that  title  (page  543  et  seq.). 

The  Acupressure. — Acupressure  for  the  control  of 
haemorrhage  was  devised  by  Sir  James  Y.  Simpson, 
and  is  used  much  less  than  formerly.  It  is  applied  in 
many  ways  ;  the  methods  of  the  application  may,  how- 
ever, be  reduced  practically  to  two  in  number :  one, 
where  the  pin  is  carried  through  the  soft  parts  tinder 


Fig.  93. 

Fig.  94. 

Fig.  95. 

\r 

Pin  above 

Oblique  inser- 

Pin beneath 

Fig.  93 

vessel. 

tion  of  pin. 

vessel. 

Trendelenburg's  rod 

the  vessel,  and  the  point  elevated  and  pushed  through  at  an  angle  sufficient 
to  cause  it  to  tightly  close  the  lumen  of  the  artery  by  pressing  the  vessel 
against  the  overlying  tissues  (Fig.  95). 

If  this  means  be  not  effective,  additional  pressure  can  be  made  by  passing 
beneath  each  extremity  and  obliquely  above  the  pin  several  turns  of  cotton 
yarn  or  of  the  ordinary  silk  ligature.  The  other  method  is  the  reverse  of  the 
first,  the  pin  resting  upon  and  pressing  the  vessel  downward  upon  the  deep- 
seated  tissue,  instead  of  upward  against  the  superficial  (Figs.  93  and  94). 
Acupressure  is  often  employed  to  arrest  htemorrhage  from  small  branches  of 


76 


OPERATIVE  SURGERY. 


Fig.  96. — Buck's  needle  conductor. 


the  palm  of  the  hand  and  in  other  similarly  constituted  structures.  The 
distance  from  the  open  end  of  the  vessel  to  the  point  at  which  the  pressure 
is  applied  depends  on  the  size  of  the  vessel — if  large,  within  one  half  inch ; 
if  smaller,  the  distance  is  lessened  proportionately  to  the  size. 

The  introduction  of  the  pin  can  be  facilitated  by  the  aid  of  Buck's  pin 
conductor  (Fig.  9C),  which  when  passed  beneath  the  vessel  and  out  through 

the  integument  at  the  oppo- 
site side  will,  on  withdrawal, 
properly  place  the  pin,  pro- 
vided the  point  of  the  latter 
be  well  inserted  into  the  open 
end  of  the  instrument.  A 
surgical  needle,  curved  or 
straight,  according  to  situa- 
tion, can  be  passed  beneath  a 
vessel  and  caused  to  effect  the 
closure  in  a  similar  manner 
as  with  the  pin. 

Circumclusion,  torsoclu- 
sion,  and  retrodusion  are 
variations  in  the  method  of  pin  pressure  arising  either  from  twisting  or 
compressing  the  caliber  of  the  vessel.  These  methods  seem  to  possess  but 
one  distinct,  practical  advantage  over  occlusion  by  catgut  ligature — viz.,  they 
can  be  more  safely  practiced  on  vessels 
with  brittle  coats  due  to  atheromatous 
and  other  changes.  The  minute  descrip- 
tion of  the  various  modifications  of  acu- 
pressure can  be  found  in  the  text-books 
and  medical  dictionaries  of  the  day. 
The  pins  are  made  of  gold,  silver,  steel, 
and  iron,  are  of  various  lengths,  have 
metal  or  glass  heads  and  differently 
shaped  points.  A  further  description  or 
an  illustration  of  them  is  not  necessary, 
since  they  can  be  readily  and  satisfac- 
torily ordered  from  the  venders  of  sur- 
gical supplies.  Shawl  pins,  ordinary 
pins,  and  needles  can  be  safely  substi- 
tuted if  required  by  the  exigencies  of 
the  case. 

The  Torsion. — Torsion  consists  in 
thoroughly  isolating  and  drawing  down 
the  end  of  the  vessel,  seizing  it  firmly 
with  a  forceps  about  half  an  inch  above  its  extremity,  and  twisting  the  end 
several  times  with  another  forceps  till  the  resistance  of  the  vessel  is  over- 
come (Fig.  97),  care  being  taken  not  to  twist  it  off.  The  blood  is  then 
allowed  to  impinge  upon  the  twisted  portion  before  the  vessel  is  released,  to 


Fig.  97. — Torsion  of  an  artery. 


AGENTS  FOR  THE   CONTROL  OF  HiEMORRIIAGE. 


77 


Pig.  98. — Hewson's  torsion  forceps. 


tost  the  completeness  of  the  occlusion.  The  twisting  produces  a  mutilation 
and  breaking  u])  of  the  coats  of  the  vessel,  which  closes  its  caliber  and  causes 
a  rapid  formation  of  the  internal  clot.  It  is  evident,  if  the  coats  be  diseased 
and  brittle,  that  nnich  caution  is  necessary  in  twisting  them,  otherwise  a 
good  basis  for  the  occurrence  of  secondary  haemorrhage  will  be  established. 
Torsion  forceps,  which  combine  in  one  instrument  the  holding  and  twisting 
forces,  have  been  recommended,  although  not  commonly  employed  (Fig. 
98).  Torsion  as 
a  substitute  for 
ligaturing  is  not 
considered  with 
much  favor  in 
this  country  ex- 
cept in  individ- 
ual instances.  It  is  commonly  employed,  however,  to  close  the  small  bleed- 
ing points  seen  on  the  surface  of  freshly  cut  wounds,  and  when  thus  em- 
ployed rarely  more  than  a  single  forceps  is  used  for  the  purpose.  Only 
the  end  of  the  vessel  should  be  seized,  to  avoid  the  unnecessary  twisting 
and  devitalization  of  the  contiguous  tissues. 

The  Forceps,  Serre-fines,  and  Tenacula. — Since  these  instruments  are 

closely  associated  in  com- 
mon usefulness,  they  can  be 
spoken  of  in  connection  with 
each  other.  The  spring- 
catch  fenestrated  forceps, 
now  rarely  used,  is  the  best. 
There  are  two  patterns  of 
these  —  Liston's  (Fig.  99), 
and  those  devised  by  Hamil- 
ton (Fig.  100). 

The  expansion  of  the 
fenestrated  extremity  carries 
the  ligature  around  the  ves- 
sel, rendering  it  practically 
impossible  to  tie  the  end  of 
the  instrument,  as  in  the 
case  of  the  Liston  forceps. 
Liston's  mouse-tooth  forceps  (Fig.  101).  while  it  is  not  suitable  for  the 
common  purpose  of  catching  bleeding  vessels,  is  nevertheless  of  great  service 
in  securing  l)leeding  points  on  flat 
surfaces,  especially  when  surrounded 
by  dense  tissues.  -^^ ..^_jifflimj|mj||||^jj|j|im 

The  serre-fine  forceps  is  of  great     ^^^^^  mi     T,vf    '  ^    ^  <• 

.  i  »  riG.  101. — Liston  s  mouse-tootli  forceps. 

utihty    m    the    control    of    bleeding 

points  during  an  operation.  It  can  be  easily  and  quickly  adjusted,  and  by 
its  continued  pressure  on  the  coats  of  the  small  vessels  tlie  necessity  of  sub- 
sequent ligaturing  may  Ije  obviated.     It  is  used  to  catch  and  control  bleed- 


FiG.  99. — Liston's  spring-catch  fenestrated  artery 
forceps. 


Fig.  100.— Hamilton's  (F.  H.)  artery  forceps. 


78 


OPERATIVE  SURGERY. 


ing  points  to  which  the  application  of  a  ligature  is  impracticable,  and  is 
often  allowed  to  remain  on  the  vessels  till  all  danger  of  bleeding  has  sub- 
sided. There  are  several  va- 
rieties of  these  instruments — ■ 
the  forceps  serre-fine,  which 
is  the  largest  (Fig.  102),  is 
admirably  adapted  to  con- 
trolling large  vessels,  and  on 
account  of  its  seizing  and  re- 
taining power  can  be  utilized 
in  grasping  and  holding  tis- 
FiG.  102.— Forceps,  serre-fine.   V  J    sues  for  other  purposes.     The 

smaller  serre-fines  (Fig.  103)  are  used  to  catch 
and  hold  small  bleeding  points  during  operation. 

Milne's  serre-fine  forceps  (a)  is  closely  allied 
in  principle  to  the  Langenbeck  (&)  and  wire 
(c)  serre-fines,  and  like  them  it  is  useful  for 
compressing  the  divided  ends  of  smaller  ar- 
teries and  the  trunks  in  their  course  through 
the  soft  tissues,  as  the  coronary  arteries  in  the 
operation  for  harelip.  The  compressor  de- 
vised by  Gross  (Fig.  104)  can  be  attached  to 
the  bleeding  point,  the  handle  unscrewed,  and 
the  blades  permitted  to  remain  until  all  dan- 
ger of  bleeding  has  ceased. 

T]ie  Tenaculum  (Fig.  105). — The  tenaculum 
is  used  to  pick  up  and  draw  outward  from  the  soft  parts  the  open  mouths 
of  vessels.  If  the  extremity  of  a  small  vessel  be  too  short  to  be  ligatured  by 
the  aid  of  forceps,  it  can  be  transfixed  along  with  a  small  portion  of  the 


Pig.  103. 
a.  Milne's  serre-fine. 
&.  Langenbeck's  serre-fine. 
c.  Wire  serre-fine. 


Fig.  104. — Gross's  artery  compressor. 

contiguous  soft  parts  by  the  tenaculum,  and  a  ligature  thrown  around  the 
combined  tissues.     If  a  nick  be  made  on  either  side  of  the  tissues  raised 

by  the  tenaculum,  the 
ligature    can    be    more 
securely     applied     and 
the  vessel  more  firmly 
grasped. 
Tlie  Forcipressure. — The  implements  bearing  this  name  are  quite  numer- 
ous and  withal  exceedingly  efficient.     While  there  are  many  deviations  in 
pattern  of  a  minor  degree,  and  for  which  distinct  advantages  are  claimed. 


Fig.  105.— Tenaculum. 


AGENTS   FOR  THE  CONTROL   OP  HiEMORRIIAGE. 


79 


still  these  variations  are  often  too  fanciful  to  be  dignified  by  special  mention. 
The  straight  and  the  curved  (Fig.  106)  are  the  patterns  now  in  constant  use, 
the  curved  perliaps  being  the  more  favored  of  the  two,  because  it  has  the 
smaller  bite,  and  obstructs  less  the  field  and  view  of  the  operator.  These 
instruments  are  strong,  convenient,  serviceable,  and  cleanly,  and  therefore 
have  superseded  almost  entirely 
the  use  of  the  older  forceps. 
Those  with  blunt  points  are  bet- 
ter aids  in  the  proper  placing  of 
a  ligature  than  are  those  with 
slender  points,  for  obvious  rea- 
sons. The  T-shaped  one  is  some- 
times employed  to  check  oozing 
of  extended  surfaces. 

The  Cautery. — Cautery,  which 
was  once  a   common   means   of 

controlling  haemorrhage,  has  now  but  a  limited  application  for  this  purpose. 
There  are  three  varieties  in  common  use — the  actual,  the  thermo-,  and  elec- 
tro-cauteries. The  actual  cautery  requires  the  employment  of  cautery  irons 
(Fig.  107),  which  should  be  accompanied  by  the  blowpipe  and  lamp,  al- 
though they  can  be  heated  by  ordinary  measures.  The  blowpipe  is  by  far 
the  best  means,  since  during  the  summer  months,  or  in  unfavorable  situa- 
tions, or  when  great  haste 


Fig.  106. — Foreipressure. 


=^ 


is  necessary,  the  domestic 
means  of  heating  them  will 
be  inadequate. 

Therm  ic  Anglo  t  ripsy. 
— Downes  combines  heat 
and  the  angiotribe,  thus 
controlling  haemorrhage  in 
major  operations  in  a  sat- 
isfactory way.* 

Thermo-Cautery. — The 
Paquelin  cautery  consists 
of  an  isolated  hollow  han- 
dle adapted  to  three  mov- 
able platinum  points,  into 
either  of  which  a  continu- 
ous stream  of  benzine 
vapor  is  introduced  by  a 
bulb  connected  by  a  tube 
with  the  bottle  containing  the  fluid  (Fig.  108),  after  the  cautery  is  lieated 
in  the  flame  of  a  spirit  lamp.  The  use  of  this  mechanism  brings  the  platinum 
point  quickly  to  the  required  temperature,  which  is  maintained  by  squeezing 
the  rubber  bulb.     If  the  benzine  vapor  he  introduced  into  the  platinum  point 


Fig.  107. — Actual  cautery,  blowpipe,  and  irons. 


*  American  Med.,  Nov.  28,  1903. 


80 


OPERATIVE  SURGERY. 


before  the  metal  is  propei'ly  heated  the  instrument  is  made  temporarily 
unserviceable — a  fact  M'hich  often  leads  to  much  vexation  and  pernicious  de- 
lay. The  range 
of  usefulness  of 
this  instrument 
is  more  extended 
than  that  of  the 
former  means  of 
cautery.  It  is 
used  not  only  for 
the  same  pur- 
poses, but  can  be 
employed  as  a 
cutting  imple- 
ment for  the  re- 
moval of  mor- 
bid growths,  etc., 
when  union  by 
first  intention 
becomes  a  lesser 
consideration 
Fig.  108.— Paquelin's  thermo-cautery.  *han  the  annoy- 


ance     from      primary 
haemorrhage. 

The  Galvano  Cau- 
tery. —  Electricity  is 
employed  for  the  pur- 
poses of  cautery  much 
more  frequently  than 
heretofore ;  and  this  is 
especially  true  in  con- 
nection with  the  destruction  of  vascular  growths  and  the  removal  of  small 
malignant  neoplasms.    The  ingenious  command  that  is  had  of  this  subtle 


Fig.  109. — Galvano-cautery  battery,  with  knife  electrodes. 


AGENTS   FOR  TilK   CONTROL  OP   HyEMORRMAGE. 


81 


Fiff 


Fig.  110. — Hand-larap  for  illumination. 


agent  enables  the  surgeon  to  perform  many  trivial  operations  with  but  little 
pain  to  the  patient  and  inconvenience  to  himself  (Fig.  109).  Storage  bat- 
teries (Fig.  110)  and  their  adaptability  for  special  ilhiminating  purposes  in 
deep  wounds,  and  also  the  oppor- 
tunity to  use  the  various  associ- 
ated devices  of  the  batteries  for 
operative  purposes,  are  of  great 
importance  (Fig.  111).  0 
!)99,  Vol.  II. 

The  Ligature. — The  liga- 
ture is  by  far  the  best  agent 
for  the  control  of  haemor- 
rhage that  the  surgeon  pos- 
sesses. It  is  easily  portable, 
can  be  readily  applied,  and 
is  always  obtainable  in  some 
form.  Ligatures  are  classi- 
fied, according  to  their  na- 
ture, into  the  organic  and 
inorganic.  The  organic 
comprise  the  hemp,  silk, 
and  catgut  varieties,  and  for  convenience  should  not  be  less  than  twelve 
to  sixteen  inches  in  length,  and  longer,  even,  should  circumstances  require. 
A  ligature  should  be  of  sufficient  strength  to  withstand  the  traction  neces- 
sary to  meet  the  demand 
for  its  use.  Its  size  should 
depend  somewhat  upon  the 
force  to  be  employed  in  the 
tying  and  the  area  of  the 
seat  of  constriction.  The 
requisite  force  to  properly 
occlude  a  vessel  can  not 
be  practically  estimated  by 
ounces,  but  is  largely  a 
matter  of  observation.  The 
traction  should  be  made 
steadily  over  the  ends  of 
the  forefingers  or  thumbs, 
and  without  disturbing  the 
relation  of  the  vessel  to  its 
surrounding  parts  (Fig. 
112).  The  giving  away  of 
the  inner  coat  of  a  vessel 
indicates  that  the  ligature 

is  drawai  sufficiently  tight,  but  this  sensation  is  not  noticeable  except  in  con- 
nection with  the  larger  vessels.  The  firm  apposition  of  the  surfaces  of  the 
inner  coat  without  division  is  adequate   for  the  purpose,  but  in   usual 


Fig.  111.— Head-lamp  for  illumination. 


82 


OPERATIVE  SURGERY. 


Fig,  112. — Tying  a  ligature. 


practice  the  complete  division  of  this  coat  is  made,  unless  the  vessel  be  large 
or  much  diseased,  when  the  former  practice  is  regarded  the  safer,  as  it  is  fol- 
lowed less  frequently  by  secondary  hsemorrhage.  Great  caution  is  to  be 
exercised  to  prevent  other  tissues  than  the  walls  of  the  vessel  from  being 
included  in  the  grasp  of  the  ligature,  but  when  the  vessel  is  diseased,  not 

infrequently  small 
portions  of  contig- 
uous soft  tissues 
are  taken  in  to  pre- 
vent undue  sever- 
ance of  the  arterial 
walls.  In  such  in- 
stances two  liga- 
tures can  be  ap- 
plied a  short  dis- 
tance apart.  The 
first  one  is  applied 
near  the  end  of  the  vessel  and  firm  enough  to  close  the  lumen  entirely.  The 
second  above,  tight  enough  to  nearly  arrest  the  flow  of  blood.  The  second 
one  protects  the  first  from  undue  impulse,  and  between  the  two  a  clot  is 
quickly  formed.  The  writer  has  practiced 
this  plan  in  several  instances  in  greatly 
diseased  arteries,  with  prompt  and  per- 
manent closure  on  each  occasion.  If  a 
nerve  be  tied  in,  the  patient  may  be  tor- 
mented by  pain,  which  may  not  cease  even 
with  the  disappearance  of  the  constrict- 
ing agent. 

Knots. — The  security  of  the  ligature  depends  very  much  on  the  kind  of 
knot  employed  in  the  tying.  All  knots  are  insecure  unless  carefully  tied. 
The  surgeons  or  the  friction  hnot  is  formed  by  making  two  turns 
of  the  ligature  at  the  first  loop  instead  of  one  (Fig.  113).  It  will  not 
slip  if  it  has  been  drawn  tightly;  it  is  wisely  employed  in  tying  a  ves- 
sel beyond  the  sight 
of  the  surgeon,  be- 
cause then  the  first 
half  of  a  reef  knot 
may  slip  without  his 
knowledge,  thereby 
resulting  in  an  im- 
perfect closure  of  the 
vessel.  It  is  proper 
to  say,  however,  that 
when  this  knot  is  supplemented  by  turns,  two  should  be  employed,  as  a  single 
turn  tends  to  cause  relaxation  of  the  first  two  and  thus  lessens  its  security. 

It  sometimes  happens,  when  a  silk  ligature  is  saturated  with  blood  or 
other  fluid,  that  the  first  half  of  the  knot  can  not  be  drawn  as  tightly  as  it 


Fig.  113. — Surgeon's  knot. 


Fig.  114.— Reef  knot 


Fig.  115. — Granny  knot. 


AGENTS  FOR  THE  CONTROL  OP  HEMORRHAGE. 


83 


Fig.  IIG. — First  step  in  tying  reef  knot. 


should,  owing  to  the  l)in(ling  of  the  thread;  thus  an  insecure  fastening 
is  made,  even  when  it  is  fortilied  by  overlying  turns. 

The  Reef  or  Square  Knot. 
— This  form  of  knot  is  com- 
monly employed  in  tying  a 
vessel.  The  reef  knot  (Fig. 
114)  is  easily  confounded 
with  the  "  granny  knot " 
(Fig.  115),  which  is  insecure. 
The  following  description  of 
the  method  of  tying  the  reef 
knot,  taken  from  Heath,  is 
too  graphic  to  be  substituted 
by  any  other :  "  The  ligature  is  held  in  the  palm  of  the  right  hand,  between 
the  thumb  and  finger;  the  end  is  then  thrown  around  the  forceps  closely 
and  caught  with  the  left  hand,  and 
carried  across  the  right  thuml)  and 
inserted  between  the  third  and 
fourth  fingers  of  the  right  hand 
(Fig.  116).  The  left  at  the  same 
moment  seizes  the  other  end,  and 
the  ends  of  the  threads  are  drawn 
out,  as  is  demonstrated  in  Fig. 
117.  There  will  now  be  no  diffi- 
culty in  drawing  the  knot  thus 
formed  tight  with  the  forefingers 
(Fig.  118),  or,  if  preferred,  with 
the  thumbs.  To  complete  the  knot 
by  making  an- 
other   tie,    the 

same  maneuver  is  to  be  effected,  taking  care  always  to 
begin  with  the  opposite  hand  to  that  which  began  before. 
It  is  quite  immaterial  which  hand  begins  the  first  part  of 
the  knot,  so  long  as  the  opposite  one  always  begins  the 
second  part;  in  this  way,  with  a 
little  practice,  the  reef  knot  may 
be  unerringly  tied  with  the  great- 
est rapidity."     When  the  knot 
is  completed  it  will  be  seen  that 
the  ends  of  the  ligatures  lie  par- 
allel with  and  in  contact  with  the 
portion    of    the   ligature   which 
surrounds  the  vessel. 

Great  care   should  be   exer- 

.    cised  after  the  proper  tightening 

of  the  first  fold  of  the  knot  not  to  disturb  it  by  making  the  ends  tense 

during  the  tying  of  the  second  part,  for  if  the  first  part  be  then  loosened 


Second  step. 


Fig.  118.— Third  step. 


84: 


OPERATIVE   SURGERY. 


Pig.  119.— Staffordshire  knot. 


and  the  loosening  pass  unnoticed,  the  placing  of  the  second  part  will  make 
the  completed  knot  very  insecure.     Catgut  can  be  tied  with  the  surgeon's 

or  the  reef  knot,  but  it  is  less  secure  than  silk. 
Therefore,  when  catgut  is  applied  to  a  large 
vessel  an  additional  tie  should  be  given,  irre- 
spective of  the  kind  of  knot. 

The  Staffordshire  Knot  (Fig.  119).— The 
Staffordshire  knot  is  used  in  tying  pedicles. 
It  is  formed  by  carrying  the  ligature  through 
the  pedicle  and  returning  the  needle  so  as  to 
leave  a  loop  at  the  distal  side.  The  loop  is 
then  slipped  over  the  pedicle  and  the  free 
ends  are  carried  one  above  it,  the  other  below, 
where  they  are  tied  together  with  a  reef  knot. 
This  knot  may  slip. 

The  elaborate  studies  of  Ballance  and  Ed- 
munds of  the  question  of  knots  and  their  tying,  especially  of  the  larger 
vessels,  emphasize  in  no  uncertain  manner  the  importance  of  the  use  of 
their  "  stay  knot." 

The  Floss-Silk  Stay-Knot. — This  variety  of  knot  is  made  as  follows: 
Carry  around  the  vessel  two  ligatures  of  soft  floss  silk,  lying  side  by  side 
and  parallel  with  each  other  (Fig.  130)  ;  tie  each  independently  with  equal 
force,  half  of  a  square  knot,  using  sufficient  traction 
to  firmly  coapt  the  inner  walls  of  the  vessel  without 
causing  rupture,  but  arresting  entirely  the  flow  of 
blood,  grasp  conjointly  the  ends  of  the  ligatures  at 
either  side  of  the  vessel  and  gently  tighten  the  half 
knots  if  practicable.  Complete  the  tying  by  uniting 
the  two  ends  at  each  side,  and  using  them  as  one  in 
finishing  the  knot.  The  innominate  can  be  wisely 
ligatured  by  this  method  of  tying  (Figs.  207,  208). 
Catgut  and  other  agents  for  ligaturing  are  employed 
in  a  similar  way,  using  two  or  more  strands  for  the 
purpose,  according  to  the  size  of  the  vessel,  the  degree 
of  force  of  the  circulation,  and  the  structural  in- 
tegrity of  the  coats.  However,  the  floss-silk  knot 
is  softer  than  that  formed  by  the  preceding  firmer 
agents,  and  therefore  less  liable  to  cause  unequal  pressure  of  the  constricted 
vessel  and  the  greater  danger  of  hemorrhage  that  attends  their  use. 

The  atrophy  of  the  inner  coats  of  vessels  caused  by  the  compression  of 
the  ligatures,  when  not  attended  with  division  of  these  structures,  is  variable, 
being  modified  in  its  extent  by  the  degree  and  the  area  of  the  compressing 
force,  also  by  the  actual  state  of  the  circulation  in  the  tissues  themselves. 

It  will  be  noted  (page  162  et  seq.)  that  in  ligature  of  the  innominate 
this  variety  of  knot  is  especially  indicated,  and,  moreover,  it  is  not  at  all 
uncertain  that  in  the  successful  outcomes  of  ligatures  of  this  important 
vessel  the  stay-knot  of  Ballance  and  Edmunds  has  contributed  no  unim- 


FiG.  120.— The  floss-silk 
stay-knot.  «.  The  com- 
bined fold,  completed 
knot.  b.  The  inde- 
pendent single  folds. 


AGENTS  FOR  THE  CONTROL  OF  HAEMORRHAGE. 


85 


DOUBLE  TURN.      FRICTION  KNOT 


-    SINGLE  TURN, 


SINGLE  TURN. 


REEF  KNOt 


portant   factor   to   the   manner   of   the   application,   also   no   insifjnificant 
amount  of  the  favorable  features  of  spinal  cases  can  be  justly  attributed. 

The  difficulty  of  the  removal  of  deep-seated  ligatures,  especially  when 
connected  with  pedicles,  is  not  a  new  or  trifling  matter.  Dr.  Grad  has  de- 
vised the  following  ingenious  and  excellent  plan  for  the  loosening  and  re- 
moval of  this  class  of  ligatures  (Fig.  121).  As  will  be  noted  in  the  illustra- 
tion, an  independent  traction  loop  is  included  beneath  each  fold  of  the 

ligature  in  the  tying 
of  the  knot,  and  the 
order  of  the  relation 
to  the  surface  of  the 
respective      loops     is 
indicated  numerically 
by  knots  tied  in  them. 
One  end  of  the  liga- 
ture   is    cut    short  to 
permit  more  readily  the  displace- 
ment by  the  traction  loops.     If 
gentle,  alternate  traction  be  made 
on  loop  No.  1  and  on  the  longer 
end    of   the  ligature,  the   third 
fold  of  the  knot  is  quickly  un- 
fastened ;    and    each    preceding 
fold    can   be   untied   by  similar 
traction  directed  in  a  correspond- 
ing manner. 

Silk,  catgut,  kangaroo  ten- 
don, silkworm  -  gut,  horsehair, 
and  silver  wire  constitute  the 
standard  materials  now  employed 
for  the  purposes  of  ligatures  and 
sutures.  The  last  three  are  rare- 
ly used  as  ligatures,  except  to 
meet  fancied  or  emergency  de- 
mands. Silk  and  catgut  are 
the  standard  ligatures,  kangaroo 
tendon  being  rarely  employed 
for  the  purpose. 

Sill-. — Silk  is  employed  constantly  in  various  forms  and  sizes  for  liga- 
turing and  suturing.  It  is  fitted  especially  for  integumentary  and  intestinal 
sewing,  and  the  ligature  of  pedicles  and  other  large  masses  of  tissue.  When 
employed  for  intestinal  suturing  the  black  silk  is  advisable,  as  it  can  be 
easily  seen  and  accurately  placed.  Silk  as  a  ligature  has  the  following  advan- 
tages: It  is  cheap,  easily  obtained  and  sterilized,  readily  applied,  and  remains 
firmly  fixed  if  properly  tied.  However,  it  is  comparatively  readily  infected 
both  within  and  without  the  wound,  and  the  use  is  frequently  attended  with 
suppuration  of  the  stiteh-hole  variety.    *S(7/i-  is  sterilized  by  boiling  in  a  one- 


3  KNOTS 


Fig.  121. — The  Grad  method  of  ligature  removal. 


86 


OPERATIVE  SURGERY. 


per-cent  aqueous  solution  of  washing  soda  for  ten  minutes,  or  by  steaming 
in  a  sterilizer  for  fifteen  minutes.  It  can  be  thus  treated  in  skeins  or  while 
-wound  loosely  on  glass  spools  or  bobbins  (Figs.  123, 123).  After  washing  out 
the  soda  by  a  few  moments'  immersion  in  pure  boiling  water  the  ligatures 
can  then  be  properly  preserved  in  sterilized  glass  tubes  plugged  with  cotton, 
or  in  wide-mouthed  bottles  (Fig.  124)  containing 
alcohol  or  other  proper  antiseptic  fluid.  Strong 
solutions  of  carbolic  acid  are  objectionable  for 


^ 


MBi 


i) 


Pig.  123.— Silk  on  spools. 


Fig.  122.— Bobbins  for 
ligatures. 


Pig.  124.— Wide-mouthed 
bottle  for  ligatures. 


this  purpose,  since  they  impair  the  integrity  of  the  fiber.     A  strict  surgical 
technique  enjoins  the  use  of  freshly  prepared  silk  on  each  occasion. 

Catgut. — Catgut  is  used  extensively  as  ligatures  and  sutures.  The  best 
catgut  is  that  which  comes  from  Germany  in  the  form  of  violin,  guitar, 
or  banjo  strings.  Only  the  very  best  should  be  used.  In  general  it  will 
be  found  that  only  five  sizes  are  required.  Manufacturers  are  in  the  habit 
of  designating  the  size  of  catgut  by  numbers,  and  those  of  different  makers 
frequently  stand  for  different  thicknesses  of  gut — a  fact  which  should  be 
borne  in  mind  when  prepared  catgut  is  ordered  from  a  dealer.  Catgut 
is  the  rival  of  silk  in  surgical  technique,  and  the  question  which  is  the 
better  is  not  yet  finally  settled,  except  in  individual  minds  and  for  special 
purposes.  Catgut  is  of  uncertain  strength,  and  therefore  not  at  all  times 
reliable  for  the  ligature  of  pedicles  and  larger  portions  of  tissue.  It  slips 
more  readily  than  silk,  hence  greater  caution  is  needed  in  tying;  it  is  steril- 
ized with  great  difficulty  and  labor,  and  for  these  reasons  may  invite  care- 
lessness and  infection ;  it  is  sometimes  not  easily  obtainable,  and  therefore 
ought  not  to  be  relied  on  too  exclusively.  Catgut  is  less  reliable  for  integu- 
mentary sewing  than  silk,  as  it  causes  more  irritation  and  is  less  durable ;  but 
for  the  ligature  of  vessels  and  the  obliteration  of  dead  spaces,  properly  pre- 


AGENTS  FOR  THE  CONTROL  OP   IItEMORRIIAGE. 


87 


pared  and  carefully  applied,  catgut  is  the  most  useful  of  all  agents.  Fow- 
ler, of  Brooklyn,  prepared  catgut  by  boiling  in  alcohol  one  hour.  When 
sealed  in  small  glass  tubes  (Fig.  135)  and  thus  treated,  and  tlic  tubes 
broken  at  the  time  of  use  of  the  ligatures,  the  strictest  asepsis  is  secured. 

Preparation  of  Catgut  at  Bellevue  llosjntal,  New  York,  and  its  De- 
pendencies.— The  late  Dr.  Charles  Eice,  the  eminent  chemist,  and  the 
pharmacist  of  Bellevue  and  the  Allied  Hospitals,  for  years  prepared  excel- 
lent catgut  as  follows: 

"  Two  kinds  of  catgut  are  generally  used,  the  smooth  and  the  rough. 

"  1.  Tlie  Smooth  Catgut. — This  is  the  best  quality  of  imported  smooth 
banjo  and  violin  strings,  put  up  in  boxes  containing  thirty  strings  each, 
and  of  the  following  sizes : 


Designation. 


Banjo  1  (thinnest) . 

Banjo  2 

Violin  E 

Violin  A 

Violin  D  (heaviest). 


Average  length 
of  each  string. 


671^  inches. 

m     " 

44+       " 
44|      " 


Average  break- 
ing strain  of  each 
string  (raw). 


5  pounds. 

8 
18 
24 
32 


"  The  first  three  sizes  are  those  mostly  in  use.  Each  string  or  coil  is  tied 
in  two  places  with  silk,  which  should  be  white,  not  colored,  because,  if  colored, 
the  tint  will  be  more  or  less  transferred  to  the  catgut 
when  boiled  with  ether  or  alcohol. 

"2.  The  Rough  Catgut.  —  This  is  the  kind  for 
clockmakers'  and  jewelers'  use.  It  is  usually  in  strings 
of  five  metres  in  length,  of  various  thicknesses,  and 
tied  with  itself.  The  smaller  sizes,  Nos.  00,  0,  1,  2, 
and  3,  are  those  most  generally  in  use. 

"  If  smooth  catgut  is  to  be  boiled  in  ether  or  strong 
alcohol,  the  string  of  silk  with  which  it  is  tied  need 
not  be  removed,  for  neither  of  these  liquids  will  alter 
the  regular  circular  form  of  the  coils  or  cause  them  to 
twist.  But  if  this  catgut  is  to  be  heated  to  a  tempera- 
ture over  about  200°  F.  in  oil  of  turpentine,  vaseline, 
paraffin  oil,  albolene,  or  other  similar  liquids,  the  ties 
must  be  removed,  as  they  do  not  expand  equally  with 
the  gut,  and  are  apt  to  strangle  it  or  almost  cut  it  in 
two.  Each  coil  must  be  opened  and  securely  wound 
on  some  kind  of  reel  or  bobbin,  so  as  not  to  twist  or 
snarl.  In  the  absence  of  any  specially  prepared  reels 
the  coils  may  be  wound  on  the  outside  of  a  test  tube,  several  strings  being 
tied  together  if  necessary,  the  two  free  ends  being  secured  with  wire.  The 
test  tube,  properly  weighted  with  shot  or  otherwise,  is  then  immersed  in 
the  hot  liquid  for  the  prescribed  time.  Upon  removal  the  coils  will  retain 
their  spiral  shape. 

"  In  any  case,  when  catgut  is  to  be  heated  to  a  temperature  over  about  200"^ 


Fig.  125.— Catgut  in 
glass  tubes. 


88  '  OPERATIVE  SURGERY. 

F.  in  any  of  the  above-mentioned  or  similar  liquids,  it  must  first  be  perfectly 
dried,  otherwise  the  heat  of  the  liquid  will  cause  the  moisture  in  the  gut  to 
be  expelled  in  fine  bubbles,  and  this  will  make  it  brittle  and  rotten. 

"  In  preparing  catgut  for  surgical  use  the  principal  object  to  be  kept  in 
view  is  to  render  and  keep  it  absolutely  sterile.  This  is  accomplished  either 
by  macerating  and  preserving  the  gut  in  some  efficient  bactericidal  and 
antiseptic  liquid,  or  by  subjecting  it,  while  immersed  in  a  suitable  liquid,  to 
a  sufficiently  high  temperature,  or  by  both  methods  combined. 

"  The  Removal  of  Fat. — All  catgut  contains  a  certain  amount  of  fat. 
Although  fat  may  be  rendered  sterile  while  in  the  gut,  it  is  nevertheless 
preferable  to  remove  it  as  far  as  possible,  since  it  is  practically  a  foreign 
body,  and  may  retain  germs  which  the  antiseptic  is  unable  to  reach. 

"  The  fat  may  for  the  most  part  be  removed  by  macerating  the  gut  for  a 
number  of  days  in  ether  ('  stronger  ether ')  or  chloroform.  If  proper  facili- 
ties are  at  hand,  however,  this  may  be  accomplished  within  an  hour  by  boil- 
ing the  gut  with  enough  ether  to  cover  it  completely.  This  is  best  done 
in  a  wide-mouthed  Erlenmeyer  flask,  to  which  is  fitted  a  well-cooled  upright 
condenser,  which  causes  the  ascending  vapor  of  the  ether  to  be  condensed 
and  to  flow  back  into  the  flask,  thus  preventing  loss  of  ether.  The  heating 
should  be  done  by  steam,  in  a  place  remote  from  lights  or  fire.  After  an 
hour's  boiling  the  ether  is  allowed  to  cool  a  little,  and  is  then  poured  off. 
It  should  not  be  used  again  without  being  redistilled. 

"  Since  the  gut,  even  though  boiled  in  ether,  still  retains  at  least  as  much 
fat  as  the  amount  of  ether  in  the  interior  of  the  gut  can  hold  in  solution,  it 
is  best  to  boil  it  again  in  absolute  alcohol  (completely  covered  thereby)  for 
one  hour.  It  is  preferable  always  to  use  absolute  alcohol,  though  the  ordi- 
nary official  alcohol  (ninety-four  per  cent  by  volume)  may  be  used  if  the 
other  is  not  at  hand.  Should  the  percentage  strength  of  the  official  alcohol 
fall  materially  below  ninety-four,  there  is  danger  of  causing  the  gut  to  soften, 
gelatinize,  snarl,  and  become  rotten. 

'■'•Sterilization  and  Preservation  of  Catgut  hy  a  Solution  of  Bi^iiodide  of 
Mercury  in  Chloroform. — After  the  catgut  has  been  deprived  of  fat  in  the 
manner  stated  it  is  at  once  transferred  to  '  chloroform  with  biniodide '  (a 
saturated  solution  of  the  latter  in  the  former,  of  the  strength  of  about  1 
to  1,000)  which  completely  penetrates  it  and  renders  it  sterile.  It  is  kept 
in  this  liquid  in  vessels  provided  with  well-fitting  glass  stoppers  until  required 
for  use. 

"  Sterilization  of  Catgut  by  heating  it  with  Alcohol, preferably  under  Pres- 
sure.— Some  surgeons  prefer  catgut  that  has  been  sterilized  by  alcohol  and 
heat  alone.  Since  alcohol,  at  the  ordinary  pressure  of  the  atmosphere,  boils 
at  about  176°  F.,  this  temperature  is  not  always  sufficiently  high  to  destroy 
the  vitality  of  certain  germs.  Hence  it  is  preferable  to  apply  the  heat 
in  such  a  manner  that  the  vapor  of  the  alcohol  will  be  under  pressure.  For 
most  purposes  the  pressure  will  be  high  enough  if  the  vessel  is  surrounded 
with  steam  or  boiling  water.  If  possible,  however,  a  temperature  of  120° 
C.  (248°  F.)  should  be  aimed  at,  and  this  may  easily  be  reached  by  exposing 
the  vessel  to  moist  steam  under  pressure  in  a  suitable  apparatus. 


AGENTS  FOR  THE   CONTROL   OF  HEMORRHAGE.  89 

"  When  such  an  apparatus  is  not  available,  the  following  method  will  sufl&ce 
in  most  cases :  Roll  each  string  of  catgut  into  a  coil  of  such  a  diameter  that 
a  number  of  them  will  readily  go  into  a  so-called  one-ounce  glycerin  jelly 
jar.  If  the  gut  is  stiif,  it  is  best  to  tie  each  coil  in  two  places  with  fine  alum- 
inum wire.  Fill  as  many  jars  as  may  be  convenient,  and,  having  inserted  an 
extra  well-fitting  rubber  washer  into  each  lid,  and  having  poured  into  each 
jar  enough  absolute  alcohol  to  fill  it  completely,  screw  on  the  lids  as  tightly 
as  possible,  and  place  the  jars  inside  of  a  museum  jar  (Whitall,  Tatum  & 
Co.'s)  which  had  previously  been  tested  and  found  to  stand  the  intended 
pressure.  Pour  into  the  museum  jar  enough  alcohol  to  cause  the  jelly  jars 
to  stand  in  about  two  inches  of  liquid,  and  then  screw  on  the  lid  of  the 
museum  jar,  having  first  interposed  a  rather  thick  soft-rubber  washer.  Tie 
a  stout  cloth  around  the  jar,  so  that  if  it  should  burst  through  excessive 
pressure  the  fragments  may  do  as  little  damage  as  possible.  ISTow  expose 
the  jar  in  a  suitable  chamber  or  apparatus — first,  to  a  very  gentle  current  of 
steam,  to  heat  it  gradually,  and  afterward  to  a  stronger  current,  so  as  to  have 
it  constantly  surrounded  by  steam,  and  keep  it  thus  for  about  five  hours. 
If  steam  is  not  available  for  this  purpose,  the  jar  may  be  immersed  (weighted 
down,  if  necessary)  in  water  in  a  capacious  vessel,  the  water  gradually 
brought  to  a  boil,  and  maintained  thus  during  the  required  time.  When 
the  jar  is  removed  from  the  steam  or  boiling  water  it  should  be  allowed 
to  cool  gradually  and  spontaneously. 

"  If  upon  removal  of  the  museum  jar  it  is  seen  that  there  remains  at  least 
a  part  of  the  alcohol  surrounding  the  jelly  jars,  and  if  each  of  the  latter  still 
contains  the  whole  or  at  least  part  of  the  absolute  alcohol  which  had  been 
poured  in,  this  is  adequate  proof  that  the  tension  of  the  vapor  inside  of 
the  apparatus  during  the  whole  time  has  been  sufficiently  high.  If,  how- 
ever, the  whole  of  the  alcohol  in  the  bottom  of  the  museum  jar,  and,  in  ad- 
dition, the  larger  portion  or  all  of  the  absolute  alcohol  in  the  jelly  jars 
should  have  disappeared,  this  indicates  that  there  was  a  leak,  and  that, 
consequently,  the  pressure  was  not  high  enough.  The  operation  must  then 
be  repeated  under  stricter  precautions. 

"  Upon  removal  of  the  jelly  jars  from  the  outer  jar  they  should  be  com- 
pletely filled  with  hot  absolute  alcohol,  securely  closed  again,  and  kept  im- 
mersed in  alcohol  in  a  tightly  closed  jar  or  other  vessel  until  required  for 
use.  Only  so  many  coils  should  be  removed  from  a  jar  at  a  time  as  may  be 
deemed  necessary  for  an  operation.  If  any  be  left  over,  they  should  not 
be  put  back  into  the  jar,  but  put  on  one  side  and  resterilized  with  the  next 
batch. 

"  Sterilization  of  Catgut  hy  being  Heated  in  some  Fatty  Liquid  at  a 
Temperature  of  about  135°  C.  {275°  F.). — In  order  to  insure  still  more 
perfectly  the  sterilization  of  catgut,  the  following  method,  based  upon  sug- 
gestions made  by  Dr.  William  E.  Studdiford,  has  gradually  been  elabo- 
rated at  Bellevue  Hospital : 

"  Catgut  of  the  various  sizes,  having  first  been  boiled  in  ether  and 
absolute  alcohol,  and  having  then  been  kept  immersed  for  some  time  in 
'  chloroform  with  biniodide,'  is  wound   on  wooden  bobbins.     Each  bobbin 


90  OPERATIVE  SURGERY. 

contains  from  three  to  five  strings,  according  to  the  thickness  of  the  gut,  and 
the  ends  are  securely  fastened  at  each  end  of  the  bobbin.  The  bobbins 
(which  must  previously  have  undergone  the  following  treatment  by  them- 
selves alone)  are  then  put  into  vessels  containing  albolene,  and  heat  is 
applied  to  these  vessels  by  means  of  a  bath  of  petrolatum.  The  tempera- 
ture of  the  latter  is  run  up  until  that  of  the  albolene  reaches  275°  F.,  where 
it  is  maintained  by  properly  regulating  the  heat  during  at  least  fifteen 
minutes.  The  temperature  is  then  allowed  slowly  to  fall  until  the  bob- 
bins can  be  transferred  again  to  '  chloroform  with  biniodide.' 

"  Chromicized  Catgut. — The  method  used  for  preparing  this  kind  of  cat- 
gut is,  in  all  its  essential  features,  that  recommended  by  Dr.  George  M.  Ede- 
bohls.     It  is  as  follows  : 

"  Kough  catgut  (see  above),  of  the  proper  size,  chiefly  Nos.  0  and  00,  is 
first  deprived  of  fat  by  being  boiled  with  ether.  It  is  then  wound  upon 
bobbins  of  wood,  as  many  strings  being  tied  together  as  each  bobbin  will 
hold,  the  ends  being  secured  in  notches  made  in  the  bobbins.  The  latter 
are  then  weighted  down  by  sinkers  and  completely  immersed  into  a  suf- 
ficient quantity  of  a  solution  prepared  after  the  following  formula  : 

Potassium  bichromate 22|-  grains. 

Water 15    ounces. 

Dissolve,  and  then  add 

Glycerin , 2|  drachms. 

Carbolic  acid 2^        " 

"  In  this  solution  the  bobbins  are  allowed  to  remain  during  thirty  hours. 
They  are  then  removed  and  the  catgut  at  once  wound  upon  frames  of  wood 
three  feet  long,  with  notches  a  quarter  of  an  inch  apart  at  each  end,  in  such 
a  way  that  the  gut  is  stretched,  rather  tight,  up  and  down  one  face  of  the 
board  in  parallel  rows.  It  is  now  allowed  to  become  completely  dry  at  a 
temperature  not  exceeding  45°  C.  (113°  F.),  which  will  require  a  few  days. 

"  When  it  is  completely  dry  the  gut  is  removed  in  pieces  of  the  length 
of  the  board  (three  feet),  and  the  pieces  are  rolled  into  coils  small  enough 
to  go  into  one-ounce  glycerin  jelly  jars,  each  coil  being  secured,  if  necessary, 
by  two  pieces  of  fine  aluminum  wire.  It  is  finally  sterilized  by  means  of 
alcohol  under  pressure,  as  described  above. 

"  If  it  be  found,  for  any  purpose,  too  permanent,  the  time  of  maceration 
in  the  bichromate  solution  may  be  shortened  in  proportion. 

"  This  chromicized  catgut  is  now  also  sterilized  by  the  albolene  method 
mentioned  in  the  preceding  paragraph." 

The  following  simple  plan  of  sterilization  is  quoted :  "  Put  into  a  jar  a 
pint  of  absolute  alcohol  and  the  catgut ;  cover  the  jar  tightly  with  a  lid,  on 
which  may  be  placed  an  ice  bag  to  hasten  condensation  of  the  vapor  coming 
from  the  boiling  alcohol.  If  the  alcohol  evaporate  and  leave  the  gut  ex- 
posed, or  the  temperature  long  exceed  200°  F.,  the  catgut  is  rendered  useless 
by  the  fallacies  of  the  method  itself." 

Ligatures  when  prepared  are  put  up  in  small  wide-mouthed  glass  recep- 
tacles (Fig.  126),  and  can  be  utilized  as  desired.  Larger  receptacles  for  hos- 
pital and  office  use  are  convenient  and  efficient  (Fig.  127).  Halsted  practices 


AGENTS  FOR  THE   CONTROL  OF  HiEMORRIIAGE. 


91 


the  following  simple  and  efficient  method  of  sterilizing  and  preserving  liga- 
tures and  sutures :  The  material  is  wound  on  small  glass  reels,  and  these  are 
put  into  a  screw-topped  small  glass  jar  containing  alcohol.  The  cover  of 
the  small  glass  jar  is  loosely  screwed  down  upon  its  rubber  washer,  and  then 
this  jar  is  put  into  a  still  larger  one,  three  quarters  filled  with  alcohol,  at- 
tached to  the  condenser,  and  after  an  hour's  boiling  the  small  jar  is  removed, 
the  cover  tightly  screwed  down,  and  the  ligatures  and  sutures  not  disturbed 

until  needed  for  use.  Then  the  bobbins  can 
be  removed  one  at  a  time  as  needed,  and  the 
material  unwound  by  grasping  the  bobbin 
between  the  thumb  and  finger  so  as  not  to 
touch  the  gut. 


Fig.  126,— Wide-mouthed 
bottle  for  catgut. 


Fig.  127. — Ligature  receptacle  for  office  and 
hospital  use. 


Von  Bergmanri's  Method  of  pre^paring  Catgut  is  the  following :  Steril- 
ize the  glass  disk  in  which  the  catgut  is  to  be  placed,  by  steam,  for  three 
quarters  of  an  hour ;  wind  the  gut  on  the  glass  bobbins ;  cover  with  ether 
for  twenty-four  hours ;  pour  off  ether,  and  substitute  the  following  solution : 

Bichloride  of  mercury 10  parts. 

Absolute  alcohol 800      " 

Distilled  water 200      " 

Change  the  last  solution  daily  for  two  days  and  then  substitute  for  it 
ordinary  alcohol.     If  glycerin  (30  per  cent)  be  added,  the  gut  is  hardened. 

Konig'^s  Method. — Place  the  catgut  in  the  form  of  rings  in  the  dry  hot 
air  of  an  oven  or  sand  bath  at  a  temperature  of  158°  F.  for  two  hours ;  then 
heat  in  cumol  to  a  temperature  of  329°  F.  for  an  hour,  and  finally  transfer 
to  and  preserve  in  petroleum  benzine.  Clark  and  Miller  have  modified  Ko- 
nig's  method  as  follows :  "  1.  The  catgut,  twelve  strands,  is  rolled  in  a 
figure-of-eight  form,  so  that  it  can  be  slipped  into  a  large  test  tube.  2. 
Bring  the  catgut  up  to  a  temperature  of  176°  F.,  and  hold  it  at  this  point 
for  one  hour.  3.  Place  in  cumol,  which  must  not  be  above  212°  F.,  raise 
it  to  329°  F.,  and  hold  it  at  this  point  for  one  hour.  4.  Pour  off  the  cumol, 
and  either  allow  the  heat  of  the  sand  bath  to  dry  the  catgut,  or  transfer  it 
to  a  hot-air  oven,  at  a  temperature  of  212°  F.,  for  two  hours.    5.  Transfer  the 


92  OPERATIVE  SURGERY. 

rings  with  sterile  forceps  to  the  test  tubes  previously  sterilized,  as  in  a  labora- 
tory. In  drying  or  boiling,  the  catgut  should  not  come  in  contact  with  the 
bottom  or  sides  of  the  vessel,  but  should  be  suspended  on  slender  wire  sup- 
ports or  placed  upon  cotton  loosely  packed  in  the  bottom  of  the  beaker 
glass.  Cumol,  which  is  of  a  clear  limpid  or  slightly  yellowish  appearance 
when  procured  from  the  chemist,  is  changed  to  a  brownish  color  by  boiling. 
The  catgut  is  allowed  to  remain  in  the  sand  bath  until  the  excess  of  cumol 
is  driven  off  and  it  appears  entirely  free  from  any  oily  matter.  A  period  of 
one  to  two  hours  is  usually  sufficient  to  dry  it  thoroughly.  From  the  sand 
bath  or  hot-air  oven  it  is  transferred  with  sterile  forceps  to  sterile  test  tubes, 
such  as  are  used  for  culture  media,  in  which  it  is  preserved  from  contami- 
nation until  ready  for  use.  Small  quantities  should  be  placed  in  each  tube, 
to  obviate  the  necessity  of  opening  them  too  frequently.  In  conclusion,  it  is 
well  to  bear  in  mind  that  while  cumol  is  not  explosive  it  is  very  inflammable, 
and  great  care  should  be  observed  in  lifting  the  wire  screen  from  the  beaker 
glass  to  prevent  drops  of  the  cumol  from  falling  in  the  flame  or  on  the 
heated  piece  of  metal  on  which  the  sand  bath  rests,  as  it  will  take  fire,  flare 
up,  and  ignite  the  fluid  in  the  beaker  glass.  Such  an  accident  has  occurred 
three  times  in  our  experience." 

Catgut  thus  prepared  is  used  in  St.  Luke's  Hospital  of  New  York  and 
in  Johns  Hopkins  of  Baltimore  with  complete  satisfaction. 

Preparation  of  Catgut  at  the  New  York  Hospital. — "  The  raw  gut  is 
put  in  benzine  for  twenty-four  hours  to  remove  fat ;  it  is  then  wiped  dry, 
wound  on  glass  spools,  and  boiled  in  sterile  alcohol  for  an  hour  to  an  hour 
and  a  half,  the  time  varying  according  to  the  size  of  the  gut.  After  twenty- 
four  hours  the  gut  (still  remaining  in  the  alcohol)  is  boiled  for  half  an 
hour  to  kill  any  spores  which  may  remain,  and  is  then  ready  for  use.  It  is 
kept  in  sterile  alcohol  until  used." 

Dr.  F.  W.  Murray,  of  the  hospital,  to  whom  the  writer  is  indebted  for 
the  statement  of  the  above  method,  adds :  "  This  gut  has  been  satisfactory. 
Frequent  cultures  show  that  it  is  sterile,  but  it  breaks  easier  than  the  cumol 
preparation  does." 

The '■'' Jefferson  Method.'''' — The  method  of  preparation  of  catgut  in  the 
Jefferson  Hospital  is  one  of  long  trial,  extended  use,  and  is  highly  com- 
mended by  Keen. 

"  First  steep  the  gut,  as  received  from  the  manufacturer,  in  the  best 
ether ;  allow  light  gut  to  remain  in  it  for  not  less  than  twenty-four  hours ; 
heavy  gut  for  forty-eight  hours.  When  it  has  been  steeped  a  sufficient 
length  of  time  in  the  ether  transfer  it  directly  into  a  mercuric-chloride  mix- 
ture, consisting  (proportionally)  of  forty  grains  of  mercuric  chloride  and 
two  hundred  grains  of  tartaric  acid  in  twelve  ounces  of  ninety-five-per-cent 
alcohol.  Very  fine  gut  should  not  remain  in  the  mercuric  mixture  longer 
than  from  five  to  seven  minutes,  the  next  size  ten  to  fifteen  minutes,  and 
the  third  and  fourth  sizes  from  twenty  to  twenty-five  minutes  respectively. 
Before  transferring  the  gut  from  the  ether  into  the  mercuric-chloride  mix- 
ture, jars  for  keeping  it  ready  for  use  should  be  at  hand,  thoroughly  scalded, 
and  then  bathed  in  an  aqueous  solution  of  mercuric  chloride  (1  to  1,000). 


AGENTS  FOR  THE  CONTROL  OF  HAEMORRHAGE.        93 

When  the  jars  are  ready  they  sliould  be  nearly  fdled  with  alcohol  (ninety- 
j5ve  per  cent  strength),  containing  palladium  bichloride  in  the  proportion 
of  one  sixteenth  of  a  grain  (two  drops  of  a  solution  which  contains  fifteen 
grains  of  the  salt  to  the  ounce)  to  the  pint  of  alcohol  (more  of  the  true 
bichloride  of  palladium  will  not  stay  in  solution  in  alcohol,  and  when  a  pre- 
cipitate occurs  through  excess  of  the  palladium  the  whole  goes  to  the  bot- 
tom and  is  not  soluble  in  alcohol).  As  the  ^ut  is  lifted  from  the  bichloride 
mixture  it  should  be  dropped  into  the  prepared  alcohol,  and  is  then  ready 
for  use.  and  will  keep,  as  far  as  is  j'et  known,  for  any  length  of  time." 

At  the  present  time  the  preparation  of  catgut  and  other  surgical  sup- 
plies of  aseptic  and  antiseptic  character  are  provided  by  manufacturers  who 
devote  skill  and  energy  to  the  perfection  of  this  class  of  products.  Cat- 
gut, especially  the  chromicized,  is  prepared  to  endure  a  longer  or  shorter 
period  of  time — five,  ten,  and  twenty  days — as  circumstances  seem  to  re- 
quire. However,  many  surgeons  do  now  and  will  continue  to  place  greater 
confidence  in  products  of  their  own  making  than  in  those  which  are  the 
outcome  of  enterprise  and  thrift. 

Ligatures  composed  of  aortic  tissue,  whalebone  tissue,  etc.,  have  been 
mentioned  for  use  in  special  purposes,  but  their  fancied  virtues  have  prop- 
erly given  to  them  only  an  ephemeral  existence. 

The  Assistants. — The  number  of  efficient  assistants  and  the  relation 
of  things  necessary  to  conduct  an  operation  with  ease  is  modified  by  its 
character. 

To  one  must  be  intrusted  the  administration  of  the  anesthetic,  watch- 
ing the  pulse,  respiration,  and  circulation  of  the  patient.  By  combining 
these  duties  the  anaesthetist  becomes  the  immediate  observer  of  the  effects  of 
the  drug,  and  he  must  be  prepared  to  carry  into  execution  the  various  ex- 
pedients that  are  recommended  for  the  ordinary  complications  attending 
anaesthesia.  If  the  temporal  and  radial  pulsations  be  compared  before  the 
administration,  the  assistant  will  be  able  to  judge  thereafter  of  the  latter 
from  the  character  of  the  former.  This  assistant  not  only  gives  the  anaes- 
thetic, but.  when  necessary,  pushes  forward  the  lower  jaw  to  prevent  swal- 
lowing the  tongue  (Fig.  8),  and,  with  the  finger  on  the  temporal  artery  and 
eye  on  the  respiratory  movement,  he  judges  of  the  necessities  of  the  case 
without  any  interruption.  His  undivided  attention  is  demanded  for  this 
duty. 

To  a  second  should  be  assigned  the  care  of  the  instruments;  he  hands 
them  to  the  surgeon  when  asked  for.  and  returns  them  to  a  place  of  aseptic 
safety  after  being  used. 

To  a  third  may  be  intrusted  the  care  of  the  sponges  and  wipers;  he 
must  see  to  it  that  a  suitable  number  of  each  is  prepared  and  placed  at  the 
convenience  of  the  operator. 

To  a  fourth  the  care  of  the  ligatures  may  be  given,  together  with  the 
sponging  or  wiping  of  the  wound,  ligaturing  vessels,  and  otherwise  assist- 
ing, as  best  suits  the  circumstances  of  the  case  or  the  desire  of  the  operator. 

In  operations  of  invasion  of  deep  cavities,  more  especiaUij  the  abdom- 
inal, an  exact  and  verified  count  of  the  agents — gauze-pads,  sponges,  forci- 


94  OPERATIVE  SURGERY. 

pressure,  etc.,  etc. — to  he  employed  in  the  operation  should  he  made  and  re- 
corded. To  a  responsible  party,  not  otherwise  engrossed,  should  he  given 
in  charge  the  accounting  for  the  agents  thu^  employed,  avoiding  therehy 
the  retention  within  the  cavity  of  a  missing  agent.  The  operator  should 
not  assume  this  task,  for  in  the  multiplicity  of  detail  and  complications 
that  are  so  often  present  in  these  cases  he  is  unfitted  for  the  responsibility. 

The  security  of  the  bleeding  points  and  the  necessary  sponging  are  often 
done  by  the  operating  surgeon;  however,  these  are  matters  which  will  be- 
come self-regulating  as  the  operation  progresses.  While  a  greater  number 
than  four  assistants  can  be  easily  utilized  in  many  operations,  still  it  is  wise 
to  recognize  the  fact  that  any  unnecessary  display  or  expenditure  on  these 
occasions  should  be  sedulously  avoided.  If  the  surgeon  is  not  able  to  avail 
himself  of  a  suitable  number  of  assistants,  he  must  then  draw  upon  his  own 
resources.  This  is  accomplished  by  placing  the  sponges,  wipers,  and  in- 
struments where  they  can  be  conveniently  reached;  then  the  surgeon  can 
sponge,  secure,  and  tie  the  vessels.  If  the  circumstances  demand  it,  he  can 
at  the  same  time  regulate  the  administration  of  the  anesthetic,  by  observa- 
tion of  the  proper  reflexes  and  sounds  of  the  patient,  the  color  of  the  blood, 
respiratory  movements,  etc.  The  utilization  of  the  services  of  an  educated 
nurse  will  relieve  the  stress  in  such  instances. 

The  Patient  should  be  prepared  for  the  operation.  The  physical,  legal, 
and  spiritual  aspects  of  preparation  have  been  heretofore  considered  under 
various  headings,  consequently  little  remains  to  be  said  other  than  to  prop- 
erly cleanse  the  part  to  be  operated  upon. 

The  Antiseptic  Method.^In  the  antiseptic  method  everything  employed 
in  connection  with  the  preparation  for  operation,  the  operative  procedure, 
and  the  dressing  of  the  wound  is  sterilized  by  germicidal  substances  (page 
60  et  seq.). 

The  Aseptic  Method. — In  the  aseptic  method  no  antiseptic  substances 
are  employed  during  the  operation  or  the  dressing  of  the  wound,  except  to 
such  factors  of  the  procedure  as  can  not  be  properly  sterilized  by  heat. 

Therefore  the  field  of  operation,  the  hands  of  the  operator  and  of  the 
assistants,  and  the  catgut,  and  perhaps  the  drainage  agent,  are  antiseptic- 
ally  prepared  in  both  methods.  In  the  aseptic  method,  sterilized  water, 
sterilized  saline  solutions,  sterilized  wipers  and  dressings,  prepared  by  dry 
or  moist  heat,  are  exclusively  used. 

The  advantages  of  the  aseptic  method  are  substantial :  It  is  applicable 
to  all  parts  of  the  body ;  the  wounds  heal  quicker ;  the  skin  is  not  irritated, 
and  toxic  dangers  are  absent.  Inasmuch  as  aseptic  and  antiseptic  technique 
have  each  a  common  object  in  view — the  establishment  of  an  aseptic  wound 
— and  since  both  include  a  series  of  means  of  attainment  of  this  object 
which  will  be  applied  practically  as  fitted  to  the  operative  measures  that 
follow,  no  extended  individual  consideration  will  be  given  to  either  under 
its  proper  name. 

The  method  of  preparation  of  the  field  of  operation  depends  entirely  on 
its  location  and  condition.  If  the  field  have  an  epidermal  area,  it  should 
be  thoroughly  soaped  and  moderately  scrubbed  with  a  stiff  aseptic  brush  and 


AGENTS  FOR  THE  CONTROL  OF  HAEMORRHAGE.        95 

shaved  closely  tlie  day  before  the  operation.  A  thin  layer  of  green  soap 
may  then  be  applied  over  the  area  and  confined  in  place  until  morning. 
After  the  removal  of  the  soap  the  part  is  rubbed  with  a  cloth  or  scrubbed 
again  with  a  soft  brush,  all  loosened  cuticle  removed,  and  the  area  rinsed 
with  boiled  water  and  covered  with  aseptic  cloths  saturated  with  a  five-per- 
cent solution  of  carbolic  acid,  which  are  allowed  to  remain  until  the  patient 
is  on  the  operating  table  and  well  under  the  influence  of  the  anesthetic. 
The  cloths  are  then  removed,  and  the  surface  is  again  rubbed  with  the 
cleansed  hand  or  glove  with  suitable  soap,  rinsed  with  hot  boiled  water, 
followed  with  a  free  flushing  of  the  surface  with  alcohol,  ether,  or  an 
ethereal  solution  of  iodoform. 

If  the  cuticle  of  the  patient  be  sensitive,  castile,  and  even  milder  soap 
than  this,  can  be  applied.  » 

Mucous  surfaces  can  not  be  treated  thus,  for  obvious  reasons.  How- 
ever, they  can  be  scrubbed  with  a  soft  aseptic  brush  and  soap,  rinsed  with 
antiseptic  solutions,  wiped  dry,  and  covered  with  dry  antiseptic  gauze  some 
time  before  an  operative  procedure,  and  finally  cleansed  again  at  the  time 
of  operation.  These  directions  apply,  of  course,  to  the  easily  accessible  mu- 
cous-lined cavities,  like  the  mouth,  rectum,  and  vagina.  The  deep,  narrow 
ones,  as  the  urethra  and  those  of  the  nose,  can  be  thoroughly  flushed  with 
antiseptic  fluids,  which  is  all  that  can  be  practically  done.  The  use  of 
bichloride  solutions  should  be  avoided  in  those  situations. 

//  the  part  to  be  operated  upon  he  already  septic,  then,  indeed,  great 
care  and  patience  will  be  essential  to  prepare  it  so  as  to  avoid  further  in- 
fection, and  for  the  procurement  of  prompt  non-suppurative  repair.  Only 
patient  and  untiring  scrutiny  will  enable  the  surgeon  to  remove  all  foreign 
matter,  septic  agents,  and  devitalized  tissue  from  the  woimd,  and  to  cleanse 
it  so  thoroughly  thereafter  as  to  eliminate  the  possibility  of  a  remaining  in- 
fection. 

The  peroxide  of  hydrogen  is  especially  indicated  for  use  in  septic  cases. 
As  every  recess  of  the  wound  must  be  cleansed,  this  fluid  plays  an  im- 
portant and  interesting  part  by  reason  of  the  effervescent  properties  which 
dislodge  and  bring  to  the  surface  objectionable  matters. 

After  thorough  efforts  at  cleansing,  this  class  of  wounds  should  be  well 
drained  when  of  sufficient  depth  to  require  it,  and  it  may  be  necessary 
to  pack  them  lightly  with  iodoform  gauze.  The  latter  agent  not  only  asep- 
ticizes the  wound  still  further,  but  also  absorbs  the  incidental  fluids  as  well. 

The  preparations  for  operation  relating  to  the  patient,  operating  table, 
surgeon,  etc.,  etc.,  are  stated  briefly  on  page  113. 

General  Re  marls. — A  thorough  warm  bath  of  the  entire  body  of  the 
patient  should  precede  an  operation  when  practicable.  The  rapid  growth  of 
hair  in  many  instances  and  situations  requires  that  the  surface  be  shaven 
just  before  rather  than  the  day  preceding  operation,  in  order  to  secure  the 
greatest  degree  of  cleanliness.  Too  harsh  scrubbing  of  the  skin  serves 
rather  to  dislodge  and  free  the  germs  of  that  tissue  than  to  eliminate  them 
from  the  field  of  infect ivity.  The  first  scrubbing  should  be  from  three  to 
five  minutes'  duration,  the  second  and  third  somewhat  less. 


CHAPTER  III. 

THE   TREATMENT  OF  OPERATION-WOUNDS. 

It  is  necessary  to  have  the  materials  and  agents  for  the  proper  treat- 
ment of  operation-tvounds,  together  ivith  a  knowledge  of  their  use. 

As  soon  as  the  operation  is  completed  the  wound  should  be  wiped  dry 
with  a  soft  aseptic  sponge  or  wiper,  care  being  taken  to  remove  all  tissue 
shreds  and  blood  clots.  If  oozing  of  blood  be  present,  brief  firm  pressure 
with  a  dry  wiper  may  check  the  flow ;  if  not  thus  arrested,  the  wound  can 
then  be  douched  with  hot  sterilized  water,  and  pressure  again  applied.  Appli- 
cation to  the  surface  of  the  strong  solution  of  carbolic  acid  (page  48)  may 
suffice  for  the  purpose.  If,  despite  these  measures,  oozing  continues,  a  sponge 
or  wiper  saturated  with  hot  water  should  be  pushed  firmly  into  the  wound 
and  allowed  to  remain  while  the  integumentary  sutures  are  being  laid.  How- 
ever, before  tightening  the  sutures  the  agent  should  be  carefully  removed 
and  further  bleeding  watched  for.  If  the  flow  do  not  yield  to  these  simple 
measures,  and  time  be  an  important  element  in  the  case,  then  a  fine  catgut 

ligature  should  be  passed  through  the  tissue 
around  the  bleeding  area,  the  same  as  for  clo- 
sure of  a  vessel  en  masse  (Fig.  128),  and  tight- 
ened sufficiently  to  arrest  the  fiow ;  or  dry  gauze 
may  be  introduced  in  narrow  strips  and  per- 
mitted to  hang  from  the  lower  end  of  the  cut 
until  the  superimposed  sutures  are  tied,  when 
the  gauze  is  carefully  withdrawn,  and  the  deep 
wound  surfaces  pressed  firmly  together  by  proper 
bandaging,  or  by  deep  sutures  carried  so  as  to 
control  the  bleeding  surface.  The  ability  to 
Fig.  128.— Closure  en  masse.  properly  arrest  the  loss  of  blood  by  simple  meas- 
ures is  largely  a  matter  of  experience,  and  under 
no  circumstances  should  a  wound  be  finally  closed  until  hgemorrhage  is  ar- 
rested. Instead  of  closing  the  wound,  it  should  be  packed  with  gauze,  and 
the  sutures  placed;  the  wound  is  finally  closed  after  arrest  of  hemorrhage 
and  removal  of  the  gauze. 

The  proper  securing  of  the  divided  tissues  and  the  dressing  of  the  wound 
contemplate  three  important  considerations  :  1,  A  retentive  coaptation  of 
the  surfaces  of  the  wound ;  2,  Perfect  drainage,  or  the  absence  of  its  ne- 
cessity ;  3,  The  application  of  a  suitable  protective  dressing. 

The  retentive  coaptation  of  the   surfaces  of  a  wound  is  necessary  for 
prompt  healing,  and  both  the  superficial  and  deep  structures  are  of  impor- 
96 


THE  TREATMENT   OF   OPERATION-WOUNDS. 


97 


tance  in  this  respect.  Of  the  two,  it  is  more  important  for  the  safety 
and  prompt  recovery  of  the  patient  that  the  deep  tissues  be  properly  ap- 
posed, since  if  this  be  not  done  a  cavity  remains  in  which  blood 
or  pus  may  collect.  It  happens  not  infrequently  that  the  suj^er- 
ficial  tissues  unite  promptly  and  well,  while  the  deep  ones  fail, 
and  from  lack  of  coaptation  of  the  surfaces  form  "  dead  spaces," 
which  often  imperil  and  even  destroy  the  prospects  of  prompt 
recovery  by  harboring  unwelcome  products  which  cause  abscess 
or  sinous  formations,  and  thus  lead  to  a  tedious  and  protracted  re- 
covery. If  union  by  first  intention  be  a  desideratum,  the  wound 
surfaces  must  be  kept  in  perfect  coaptation.  For  this  purpose 
numerous  means  are  employed,  such  as  sutures,  bandages,  com- 
presses, adhesive  strips,  etc.,  supplemented  by  the  salutary  influ- 
ences of  rest  and  the  proper  placing  of  the  wounded  part. 

The  Sutures  are  classified  with  reference  to  their  nature, 
situation,  and  form. 

Sutures  are  of  organic  and  inorganic  nature.  The  organic 
are  most  often  employed.  Catgut,  silk  (page  71  et  seq.  and  Intes- 
tine, Vol.  II),  kangaroo  tendon,  silkworm-gut,  and  horse-hair  be- 
long to  this  class,  and  when  rendered  aseptic  they  are  in  common 
use  in  connection  with  various  surgical  procedures. 

The  catgut  suture  is  readily  absorbable,  and  often  this  pe- 
culiarly unsuits  it  for  use  in  cases  where  delay  in  this  respect 
is  requisite.  However,  the  greater  durability  of  chromicized  gut 
will  meet  unusual  requirements  by  exercising  a  restraining  influ- 
ence for  ten  or  more  days,  according  to  the  method  of  prepara- 
tion, while  scarcely  more  than  five  to  ten  days  can  be  expected 
of  the  simpler  varieties  of  gut.  Practically  speaking,  silk  and 
silkworm-gut  are  non-absorbable,  since  the  former  disappears 
long  after  the  term  of  usefulness  has  expired,  and  the  period  of 
durability  of  the  latter  is  as  yet  undetermined. 

Kangaroo  Tendon. — Kangaroo  tendon  is  a  more  recent  prod- 
uct than  catgut,  and  is  not  much  employed  except  in  those  cases 
in  which  great  durability  is  required,  as  the  union  of  bone  in 
fracture  of  the  patella,  Bassini's  method  for  radical  cure  of 
hernia,  etc.  It  and  silkworm-gut  can  be  sterilized  in  a  manner 
similar  to  that  of  catgut.  They  are  offered  for  sale  in  long  glass 
tubes  hermetically  sealed  (Fig.  129).  There  is  much  that  is 
comparatively  worthless  in  the  market. 

Silkivorm-gut. — Silkworm-gut  is  rapidly  superseding  silk  for 
the  sewing  of  cutaneous  wounds.  The  small  size,  smooth  sur- 
face, impervious  structure,  durability,  firm  grip,  ease  of  steriliza- 
tion, and  the  comparatively  little  danger  of  infection,  render 
this  material  an  admirable  agent  in  connection  with  superficial 
wound  treatment.  When  employed  in  any  situation,  the  extremities  should 
be  cut  off  as  short  as  is  consistent  with  the  safety  of  the  knot,  else  they  will 
scratch  the  contiguous  tissues  and  surfaces,  and  cling  firmly  to  the  apposed 


Fig.  129. 
Kangaroo 
tendon  in 
fflass  tube. 


98 


OPERATIVE  SURGERY. 


dressings.  The  cutting  tendenc}^  of  this  material  forbids  that  traction  be 
exercised  to  any  degree  in  closing  wounds,  as  it  quickly  cuts  through  the 
soft  parts  when  thus  employed.  It  should  not  be  used  subcu- 
\  meously.  It  can  be  sterilized  by  boiling  and  then  kept  in  glass 
tabes  (Pig.  129)  in  alcohol,  and  is  made  sufficiently  aseptic  if 
immersed  with  the  instruments  employed  in  an  operation. 
Horsehair. — Horsehair  is  an  old  and  reliable  agent  for  the 
[osure  of  superficial  integumentary  wounds  of  a  simple  nature. 
1 1  should  be  selected  with  care  from  the  back  and  upper  part  of 
r"--=^^  the  tail,  to  avoid  the  contamination  from  discharges,  carefully 
A\'ashed  with  soap  and  water,  boiled  for  an  hour  in  strong 
Icohol,  and  then  it  is  ready  for  use.  It  can  be  stored  in  glass 
1  ottles  filled  with  pure  alcohol. 

Celluloid  Thread  *  is  strong,  flexible,  ties  with  a  firm  knot, 
Qd  can  be  sterilized  without  impairment.     Its  unyielding  hard- 
1  ess  in  the  tissues  is  an  objectionable  feature. 

The  Inorganic  or  Metallic  Sutures. — The  metallic  sutures 
11  common  use  are  of  silver  and  iron  wire. 

Silver  Wire. — Silver  wire  is  the  better.     It  varies  in  size  and 

rrength,  and  can  therefore  be  employed  under  divers  circum- 

tances.     It  is  unirritating  and  strong,  and  consequently  is  used 

1  )  unite  large  and  gaping  wounds  in  which  much  traction  is 

1  squired ;  suturing  of  the  patella,  and  in  all  operations  in  which 

pproximation  by  means  of  deep  through-and-through  suturing 

1    required.     Silver  wire  can  be  easily  sterilized  with  the  instru- 

1  lents  by  boiling  in  the  soda  solution,  and  kept  for  use  in  a 

pecial  tube  (Fig.  130). 

Sutures  may  be  classed  into  the  deep  and  superficial  varieties. 
Deep  sutures  are  those  that  are  carried  deeply  through  the  tis- 
Les  from  the  external  surface  of  the  part,  for  the  purpose  of  clos- 
j  ig  the  dead  spaces  within,  or  to  properly  support  and  retain  in 
]  3sition  flaps  of  large  size  and  those  that  exercise  undue  traction. 
The  Uniting-  of  Divided  Tissues. — The  accomplishment  of  the 
I  tiion  of  tissues  requires  that  sutures  be  properly  placed.  Needles 
I  various  shapes,  sizes,  and  penetrating  powers  are  employed  for 
1  liis  purpose.  Some  needles  are  straight,  others  are  curved  ( Fig. 
131;  some  have  round-pointed  extremities,  like  the  housewife's 
1  3edle ;  others  have  cutting  edges  at  the  extremity ;  others  again 
are  formed  for  special  purposes  and  the  sewing  of  special  tissues. 
Special  tube  Needles  with  sharp  points  and  round  extremities  separate  the 
for  assorted  tissues  as  they  pass,  make  a  small  opening,  and  thus  provide  a 
silver^wire  ^^^^  ^^^  ^^^  ^^^  ligature  and  cause  a  minimum  degree  of 
hsemorrhage.  These  needles  are  used  with  comparative  difficulty. 
Needles  with  cutting  extremities  parallel  with  the  wound  sever  the  tissues 
and  form  large  gaping  punctures  (Fig.  132,  c,  d)  which  are  less  secure  and 


V 


Philadelphia  Medical  Journal,  May  10,  1900. 


THE  TREATMENT  OF  OPERATIOX-WOUNDS. 


99 


more  liable  to  bleed  than  those  made  by  needles  with  round  points  and  then 
passed  at  right  angles  with  the  sides  (Fig.  133,  a,  h).  Those  with  sharp 
points  and  round  extremities  are  adapted  to  the  sewing  of  serous  surfaces. 


straight.  Half  curve.  Full  curve.  Straight.       Half  curve.  Full  curve. 

Fig.  131. — Hagadorn's  needles,  medium  sizes.         Common  surgical  needles,  medium  sizes. 

the  others  to  integumentar}'.  Curved  needles  are  used  in  cavities  and  de- 
pressed tissues;  straight,  on  plain  surfaces. 

Needle  Forceps  or  Holders. — While  in  many  instances  a  needle  can  be 
readily   introduced  without  the  aid  of   a  holder,   still  the  accuracy  and 
steadiness  of  the  passage,  and  preservation  of  the  integrity  of  the  fingers  of 
the  surgeon,  demand  the  use  of  the  holder  on  most  occasions.    Various  use- 
ful needle-holders  are  now  in  the  market,  among  which  Figs.  133  and  134 
are    employed    for   light    sewing.      For 
heavy  work,  Figs.  135  and  136  illustrate 
the  forceps,  both  of  which  are  convenient 
and  durable.  I  I 

The  closure  of  a  wound  relates  to  its  -^ 

deep  and  superficial  parts.     If  the  deep  | 

portion  be  not  closed  first,  the  fact  that  I  I 

such  closure  can  be  readily  done  by  pres-  a  b  C  ci  y 

sure  or  other  suitable  means  should  be 

demonstrated  before  the  superficial  parts  Yig.  132.— Needle  wounds, 

are  united.     Whenever  the  outlines  of 

the  superficial  wound  will  permit,  they  should  be  made  tense  before  sewing, 
by  traction  made  in  the  long  axis  by  means  of  the  fingers  of  an  assistant, 
or  hooks  selected  for  the  purpose  (Fig.  137).  This  maneuver  contributes 
much  to  the  rapidity  and  symmetry  of  placing  the  sutures. 

The  sutures  should  be  introduced  as  near  the  free  edge  of  the  wound 
as  is  compatible  with  the  security  of  union.  The  depth  of  the  passing,  the 
distance  between  the  sutures,  and  from  the  edges  of  the  wound,  are  regu- 
lated by  the  depth,  degree  of  tension  of  the  wound,  its  location,  and  the 
nature  of  the  material  employed  for  suturing.  From  a  quarter  of  an  inch 
to  a  line  from  the  border  is  a  fair  estimate  of  the  distance  at  which  sutures 
9 


100 


OPERATIVE  SURGERY. 


may  be  properly  introduced  in  most  wounds.    If  too  near^,  they  quickly  cut 
through ;  if  too  far  away,  the  borders  overlap  or  turn  in,  and  thus  cause 
imperfect,    delayed,    and    distorted   union.      Sutures 
must  not  be  drawn  too  tight  (Fig.  138),  for  the  tissues 
thus  grasped  will  be  strangulated,  and  the  borders  of 


Fig.  133.— Hartley-      Fig.  134.— Sand's       Fig.  135.— Luer's      Fig.  136.— Halsted-Leur 
Markoe  needle-holder.       needle-holder.  needle-holder.  needle-holder. 


the  wound  will  draw  apart,  causing  delayed  union  and  disfigurement.     If 
the  integument  within  the  grasp  of  a  suture  remain  white  after  the  suture 
is  tightened,  the  suture  must  be  loosened  be- 
fore the  final  dressing  is  completed,  or  other- 
wise the  pallid  tissue  will  slough,  and  obvious 
results  will  follow. 

The  length  of  time  that  sutures  should  re- 


How  to  do  it. 


How  not  to  do  it. 


Fig.  137. — Tension  while  sewing. 


Fig.  138. 
Tension  of  sutures. 


main  in  situ  is  governed  by  the  liability  to  ulceration  and  disfigurement  that 
they  may  cause,  the  gaping  of  the  wound,  and  the  nature  of  the  suture 
material.     In  exposed  parts  of  the  body  sutures  should  be  removed  before 


THE  TREATMENT  OF  OPERATION-WOUNDS.  101 

marked  irritation  is  observed,  to  avoid  disfigurement.  In  such  eases  addi- 
tional means  of  support  can  be  employed,  such  as  adhesive  strips,  renewed 
suturing,  collodion,  etc.  The  adhesive  strips  should  be  made  as  nearly 
antiseptic  as  practicable  by  innnersing  them  in  a  hot  solution  of  corrosive 
sublimate  (1  to  500)  just  before  they  are  applied. 

The  Management  of  Dead  Spaces. — Dead  spaces  are  vacant  cavities  ex- 
isting between  wounded  tissues,  the  result  of  removal  of  connected  portions, 
or  of  the  separation  of  these  tissues.  Dead  spaces  may  be  occluded  by  the 
approximation  of  their  boundaries  through  the  agency  of  the  buried  or  the 
deep  through-and-through  sutures,  firm  bandaging,  or  the  organization  of  the 
blood  clots  that  may  form  in  them.  The  objections  to  the  buried  (page  10-i), 
and  the  advantages  of  the  through-and-through  sutures  are  quite  evident. 
The  repair  of  these  spaces  by  aid  of  blood  clot  can  be  accomplished  only  in 
the  presence  of  complete  asepsis.  The  infection  of  a  clot  thus  retained  in 
the  tissues  will  be  quickly  followed  by  abscess  formation,  and  perhaps  by 
general  constitutional  infection,  to  say  nothing  of  the  certain  defeat  of  local 
repair.  This  plan  of  action  is  best  adapted  to  the  restoration  of  gaping 
w^ounds  of  the  soft  parts,  or  a  loss  of  substance  of  the  hard.  The  technique 
of  the  method  in  the  latter  instance  will  be  considered  in  connection  with 
operative  procedures  calling  especially  for  its  employment  (page  450). 

Secondary  suturing  is  directed  to  the  unirritated  areas  contiguous  to  a 
wound,  for  the  purpose  of  lessening  or  removing  the  strain  on  the  primary 
sutures,  and  retaining  the  parts  in  proper  position  until  final  healing  takes 
place,  also  to  the  closure  of  wounds  with  granulating  surfaces.  The  special 
cautions  regarding  suturing,  and  the  proper  use  of  special  forms  of  suture, 
will  be  considered  later  on  under  the  headings  requiring  their  use. 

The  Different  Forms  of  Sutures. — The  interrupted,  continuous,  quilled, 
twisted  or  harelip,  button,  relaxation  and  coaptation,  and  three-cornered 
wound  sutures,  are  the  forms  employed  for  the  common  purposes  of  sutur- 
ing. Buried  and  subcuticular  are  modifications  of  the  use  of  these.  Other 
forms  will  be  described  with  the  operations  calling  for  them. 

The  interrupted  suture  has  a  greater  general  application  than  has  any 
other  form  (Fig.  139).     This  suture  is  made  by  passing  a  needle  armed 
with  proper  material  through  the  integument  and 
subcutaneous  tissue  of  the  borders  of  the  wound  at 
a  distance  of  a  line  or  more  from  them,  depending 
on  the  size  and  depth  of  the  wound  and  the  re- 
tractile force  of  its  tissues.    The  suture  is  then  tied  Fio.  139. 
by  a  reef  knot  drawn  with  only  sufficient  force  to           ^"^P  suture ^"^  ^^ 
appose  the  borders  of  the  wound  without  puckering 

the  skin.  The  knots  can  be  placed  at  alternate  sides  of  the  wound  or  at 
one  side  only.  The  former  is  the  better  plan,  since  if  the  dressings  cling 
to  the  knotted  extremities  of  the  sutures  their  incautious  removal  is  less 
liable  to  disturb  the  line  of  union.  If  tension  be  present,  alternating  deeper 
sutures  may  be  introduced.  Superficial  sutures  to  appose  the  borders  can 
be  introduced  between  deeper  ones  (Fig.  140).  If  silkworm-gut  be  em- 
ployed, it  should  be  tied,  if  practicable,  only  with  the  friction  knot,  for 


102 


OPERATIVE  SURGERY. 


when  thus  united  the  ends  of  the  suture  lie  close  to  the  surface  if  cut  short. 

In  the  removal  of  interrupted  sutures,  especially  of  wire,  the  suture  should 

be  so  divided  and  grasped 
as  to  secure  unobstructed 
withdrawal  (Fig.  141). 


Pig.  140. — Alternating  deep  and 
superficial  sutures. 


Fig.  141. 

Removal  of 

interrupted 

suture. 


Fig.  143. 
Continuous  suture. 


Fig.  143. — Tying  continuous  suture. 


Silver  wire  is  introduced  the  same  as  silk  or  by  a  needle  armed  with  a 
loop  of  silk  cord  to  draw  the  wire  suture  into  position.  The  sutures  are 
then  twisted  into  place. 

The  continuous  suture,  sometimes  called  the  glover's  (Fig.  142),  is  em- 
ployed to  unite  superficial  wounds  and  such  others  as  require  but  little 

force  to  cause  a  proper 
adjustment  of  the  divided 
surfaces.  It  is  made  by  re- 
peatedly passing  the  needle 
through  the  tissues  without 
cutting  the  thread,  and, 
after  fitting  the  sutures  to 
the  wound  strain,  complet- 
ing the  union  and  confin- 
ing the  end  of  the  thread 
by  means  of  a  final  suture 
formed  by  uniting  the  ends 
caused  by  division  close  to 
the  eye  of  the  needle,  with  the  end  of  the  suture  remaining  at  the  opposite 
side  of  the  wound  (Fig.  143).  The  continuity  makes  this  one  less  reliable 
than  the  interrupted  sutures. 

llie  Quilled  Suture. — The  quilled  suture  is  made  by 
passing  several  doubled  threads  through  the  lips  of  the 
wound,  half  an  inch  or  so  apart,  and  uniting  them  over 
quills,  wood,  etc.,  as  the  latter  lie  parallel  with  the  cut 
(Fig.  144).     This  suture  is  used  in  vaginal  and  perineal 

sewing,  and  when  the  clo- 
sure of  deep,  gaping 
wounds  is  required. 

The  Pin,  Twisted,  or 
Harelip  Suture.  —  The 
twisted  or  harelip  suture 
(Fig.  145)  is  made  by 
pushing  a  pin  through  the 
edges  of  the  wound  and  passing  aseptic  cotton  yarn,  narrow  strips  of  anti- 
septic gauze,  or  other  suitable  material,  around  the  pin  in  a  continuous  or 


Fig.  144. — Quilled  suture. 


Fig.  145. 
Harelip  suture. 


THE  TREATMENT  OF  OPERATION-WOUNDS. 


103 


interrupted  figure-of-eight  form,  confining  it  in  position,  and  at  the  same 
time  opposing  the  divided  surfaces  of  the  wound.  The  yarn  should  he 
changed  repeatedly,  so  as  to  prevent  undue  soiling.  If  the  yarn  he  drawn 
too  tight,  rapid  ulceration  around  the  pins  is  liahle  to  occur,  and  result  in 
pinhole  disfigurement  unless  the  traction  he  promptly  released.  The  twisted 
suture   (Fig.  14C)  is  of  great  use  in  closing  deep  wounds,  in  which  case 


Fig.  146.— Twisted  suture. 

needles  of  large  size,  and  even  skewers,  may  he  thrust  through  the  tissues. 
An  ordinary  pin  or  needle  can  he  employed,  although  those  that  are  spe- 
cially constructed  for  the  purpose  are  preferable  (Fig.  l-tT).  If  spear- 
pointed,  they  may  be  pushed  through  the  tissues  unaided,  or  Post's  or  Buck's 
pin  carrier  (page  76)  can  be  used  as  a  guide  for  their  introduction.  Pins 
with  adjustal)le  sharp  points  are  frequently  used.  At  all  events,  the  points 
should  be  removed  as  near  to  their  exit  as  is  consistent  with  the  security  of 
the  suture;  the  intervening  spaces  are  closed  with  superficial  interrupted 
sutures  when  necessary. 

The  Button  Suture  (Fig.  148).— The  button,  like  the  quilled  suture,  is 
emplo3^ed  to  approximate  the  deep  portions  of  a  wound,  thereby  relaxing  its 
borders  and  thus  permitting  them  to  be  united  with  simple  sutures  which, 
are  not  exposed  to  traction. 

The  Buried  Suture. — Buried  sutures  are  introduced  into  wounds  cut 
short,  and  closed  in  by  superficial  sutures.  Catgut,  kangaroo  tendon,  and 
silk  are  employed  to  occlude  dead  spaces,  silkworm-gut  and  metallic  su- 


104 


OPERATIVE  SURGERY. 


Fig.  148. 
Button  suture. 


Adjust- 
able 

Harelip    Post's  pin-   pointed 
pins.  carrier.  pin. 

Fig.  147. 


tures  being  objectionable.    Buried  sutures  are  employed  witbin  tbe  wound 
to  eradicate  dead  spaces  and  to  suitably  bring  in  contact  with  each  other 
/  the  several  layers  of  tissue  that 

compose  its  walls.  The  employ- 
ment of  buried  sutures  intro- 
duces into  the  wound  a  greater 
or  less  amount  of  constricting 
foreign  material^,  which  may  be- 
come the  source  of  infection. 
For  this  reason  the  practice  of 
introducing  the  buried  sutures 
has  not  as  yet  taken  so  strong 
a  hold  on  the  profession  as  their 
worth  suggests.  The  element  of 
uncertainty  connected  with  their  employment 
will  limit  it  to  expert  hands  sustained  by  un- 
doubted resources  for  some  time  to  come. 

The  Subcuticular  Suture. — Halsted  recom- 
mends the  subcuticular  suture  to  avoid  the  in- 
fecting influence  of  the  skin  coccus  incident 
to  passing  the  stitch  through  the  integument. 
The  needle  is  introduced  at  the  under  surface  of 
the  skin  at  one  side  and  passed  out  just  beneath 
the  cut  edge ;  it  is  then  passed  in  the  reverse  direction  at  the  opposite  side  and 
tied  (Fig.  1331,  Vol.  II) .    Fine  catgut,  silk,  or  wire  are  used  in  this  instance. 

The  Relaxation  and  Coaptation  Su- 
ture (Figs.  149,  150). — As  the  name 
indicates,  this  suture  is  a  double  one 
and  meets  dual  indications.  It  not  only 
approximates  the  deep  tissues  in  its 
grasp  (mattress  stitch,  a),  and  relaxes 
the  superficial  (relaxation  suture),  but 
is  employed  also  to  unite  the  relaxed 
borders  (continuous  stitch,  h)  of  the 
wound  (coaptation  suture). 

The  three-cornered  wound  sutures 
and  their  uses  are  explained  at  once 
by  the  illustrations  of  their  application 
(Figs.  151,153). 

Drainage. — Proper  drainage  is  not 
only  of  great  importance  in  securing 
successful  union  of  divided  surfaces, 
but  it  is  also  necessary  for  the  safety  of 
the  patient.  Good  drainage  is  as  potent 
a  factor  of  cleanliness  in  a  wound  as  is  good  drainage  of  a  dwelling  to  the 
healthfulness  of  its  occupants.  No  one  local  condition  peculiar  to  an  op- 
eration will  interfere  so  materially  with  the  process  of  healing,  or  expose  the 


Fig.  149. 


Fig.  150. 


The  relaxation  and  coaptation  suture. 


THE  TREATMENT   OF  OPERATION-WOUNDS. 


105 


patient  to  greater  constitutional  danger,  tlian  the  collection  and  decomposi- 
tion in  the  wound  of  fluids. 

When  the  surfaces  of  a  wound  can  be  brought  together  and  maintained 
so  as  to  obliterate  permanently  the  wound  cavity  and  dead  spaces,  no  drain- 


i 


\ 


Fig.  151. 


Fig.  152. 


Three-cornered  wound  sutures. 


age  is  needed.  But  since  the 
means  of  deep-tissue  coaptation 
are  often  imperfectl}^  applied  and 
maintained,  and  dead  spaces  es- 
cape notice,  and  fluid  collections 
not  infrequently  occur,  it  is  wise 
to  provide  for  drainage  during 
the  first  forty-eight  hours  suc- 
ceeding an  operative  procedure  of 
any  magnitude.  The  possible  presence  in  a  wound  of  bruised,  diseased,  or 
infected  tissue,  of  persistent  bloody  or  serous  oozing,  also  demands  the  estab- 
lishment of  drainage. 

Drainage  may  he  secured  through  dependent  incisions  in  the  flaps,  or, 
better  still,  by  introduction  into  the  wound  of  an  aseptic  drainage  agent. 
An  ordinary  piece  of  aseptic  rubber  tubing  (Fig.  153)  about  a  fourth  of  an 
inch  in  diameter,  with  holes  through  the  sides  at  irregular  intervals,  may 
be  inserted  through  the  most  dependent  portion  to  the  bottom  of  the  wound 
cavity ;  another  can  be  introduced  to  the  top  of  the  cavity  through  the  upper- 


PiG.  153. — Rubber  drainage  tube,  thread  fastening. 


most  angle  of  the  wound.  The  size  of  the  tube  is  regulated  by  the  size  of 
the  wound  and  the  necessity  of  providing  for  free  and  copious  discharge. 
Tubes  too  small  rather  than  too  large  are  often  employed.  It  may  be  better 
to  introduce  two  short  tubes,  one  above  and  the  other  below,  than  one 
through-and-through  long  one,  because  the  use  of  the  latter  introduces  into 
the  wound  a  superfluous  amoimt  of  foreign  material  which  does  not  meet 
an  indication  commensurate  with  the  disturbance  caused  by  its  presence. 
With  this  plan  of  drainage  the  wound  can  be  flushed  through  one  tube, 
while  the  other  permits  a  free  escape  of  the  fluid.  Eubber  drainage  tubes 
of  assorted  sizes  are  stored  in  antiseptic  fluid  contained  in  long  glass  recep- 
tacles of  similar  shape  but  larger  than  those  for  kangaroo  tendon.  AYhen 
thus  cared  for  they  are  ready  for  immediate  use. 

Drainage  tubes  should  be  fastened  securely  in  position,  so  that  they  can 
not  slip  into  the  wound.  If  a  tulje  be  missed  and  can  not  be  found  in  the 
dressings,  it  should  be  sought  for  in  the  wound  itself.    Tubes  are  fastened 


106 


OPERATIVE  SURGERY. 


Y^nONg  Vl^ay 


in  position  by  a  thread  or  catgut  passed  through  the  projecting  extremities 
and  tied  around  or  fastened  to  the  limb  (Fig.  153),  or,  better  yet,  by  the 
insertion  of  a  safety-pin  at  the  same  situation.  The  pin  should  be  inserted 
into  the  tube  in  such  a  manner  as  to  lie  smoothly  on  the  surface  and  not 
interfere  with  drainage.  To  meet  these  desires,  the  pin  should  pierce  the 
side  of  the  tube  parallel  with  the  surface  of  the  wound  (Fig.  154),  rather 

than  any  portion  of  its 
open  extremity.  If  cat- 
gut or  aseptic  thread  be 
used  to  hold  a  tube  in 
position,  it  should  be 
loosely    tied    around    the 

„      ^   ,     ^  , ,      ^    .  ,       .    „    ,     .  limb,    to    avoid    the    con- 

FiG.  154. — Rubber  drainage  tube,  pm  tastening.  ,    •    ,  •        j_i    j_  ->  n 

striction  that  may  follow 

swelling  of  the  soft  parts.  The  open  extremities  of  the  tubes  should  be 
cut  ofE  flush  with  the  soft  parts  as  nearly  as  possible.  Agents  of  wound 
drainage  should  be  removed  promptly,  because  if  allowed  to  remain  too 
long  they  provoke  a  discharge,  and  their  retention  may  serve  only  for  the 
removal  of  self-infected  products. 

A  drainage  tube  can  be  pushed  into  position  directly ;  it  is  better  if  the 
introduction  is  aided  by  means  of  a  director  or  probe  inserted  within  it, 
either  as  a  propelling  agent  or  a  guide.  It  may  be  pushed  or 
drawn  into  place  by  the  ordinary  thumb  forceps;  the  latter 
agent  is  the  better  if  the  wound  be  open.  Strips  of 
iodoform  (Fig.  155)  or  other  gauze  can  be  used  for 
drainage  purposes. 

The  decalcified  tubes  of  Neuber  are  not  accessible 
enough  to  rival  the  rubber  ones ;  moreover,  they  not 
infrequently  become  absorbed  before  the  wound  is 
sufficiently  healed  to  properly  dispense  with  the  use 
of  drainage.  Several  strands  of  antiseptic  catgut 
(Fig.  156),  horsehair,  or  silkworm-gut,  can  be  intro- 
duced loosely  and  retained  in  the  wound  when  lim- 
ited discharge  is  anticipated;  they  drain  quite  satis- 
factorily, and  the  first  is  readily  absorbed  or  can  be 
easily  removed,  as  desired.  Care  should  be  exercised 
in  the  introduction  into  a  deep  wound  of  the  bent 
ends  of  silkworm-gut,  as  its  springy  nature  will  cause 
it  to  disappear  into  the  wound  cavity,  and,  too,  the 
withdrawal  while  sprung  apart  will  destroy  the  repair 
along  the  course  of  removal.  Chicken  hones  decalci- 
fied by  a  weak  solution  of  hydrochloric  acid  may  be 
utilized,  and,  while  they  are  suitable  for  drainage,  still 
they  are  too  hard  to  be  absorbed,  and  consequently 
do  not  add  materally  to  the  surgeon's  equipment. 
Special  methods  of  drainage  will  be  described  in  connection  with  the  opera- 
tions to  which  they  are  adapted. 


"  ..^ 


\ 


V  5*/ 

\^^&  ,   / 

Fig.  155. 
Iodoform 
gauze  drain- 
age strips. 


Fig.  156. 

Catgut 

drainage. 


THE  TREATMENT  OF   OPERATION-WOUNDS.  107 

Canalization. — Canalization  is  a  term  applied  by  Neuber  to  a  method  of 
establishing  drainage  without  the  use  of  tubes.  Shalloiv  and  deep  canaliza- 
tion comprise  its  varieties.  Shallciv  canalization  is  the  drainage  of  a  shal- 
low subcutaneous  cavity  by  oval-shaped  punctures  a  fourth  of  an  inch  or  so 
in  width,  made  through  the  integumentary  flap  at  the  most  dependent  por- 
tion of  the  wound.  These  punctures  vary  in  number  and  situation  to  meet 
the  demands  of  the  case,  and  are  formed  by  a  punch  constructed  not  unlike 
the  leather  punch ;  in  fact,  the  latter  may  be  employed  as  a  suitable  substi- 
tute. Deep  canalization  may  be  directed  to  the  drainage  of  deep-wound 
cavities,  which,  when  united  by  granulation,  produce  an  objectionable 
amount  of  cicatricial  tissue.  The  integument  at  either  border  of  the  wound 
is  loosened  outward  from  its  deep  connections  to  an  extent  sufficient  to  per- 
mit the  borders  to  be  easily  drawn  or  slid  into  apposition  with  each  other 
and  carried  to  the  bottom  of  the  wound  cavity,  to  which  they  are  connected 
by  sutures.  The  surface  then  appears  concave  or  troughlike,  and  is  formed 
by  the  depressed  integument,  which  should  be  caused  to  unite  with  the 
walls  and  floor  of  the  cavity  by  first  intention.  Although  this  method  of 
cure  is  not  in  common  use,  it  is  nevertheless  of  much  utility  in  the  treat- 
ment of  bony  defects,  comprehending  assured  long  delay,  and  followed  by 
sensitive  and  objectionable  deformities  (page  358  et  seq.). 

The  Protective  Dressing. — Various  kinds  of  protective  dressings  are 
employed,  usually  now  of  a  simpler  character  than  formerly,  because  the 
attainment  of  asepsis  can  be  achieved  with  less  variety  of  dressing  than  usu- 
ally attends  the  antiseptic  method.  Simple  aseptic  gauze  and  medicated 
gauze  of  various  kinds  form  the  basis  of  the  protective  dressings  of  the  day. 
Sometimes  oiled  silk,  rubber  tissue,  rubber  dam,  etc.,  are  used  to  supple- 
ment textile  fabric  agents  in  attaining  special  ends.  However,  as  impervi- 
ous agents  prevent  proper  surface  evaporation,  causing  the  dressings  to 
become  warm  and  moist,  and  maceration  of  the  epidermis — conditions  that 
encourage  the  development  of  germs  rather  than  inhibit  them,  as  is  charac- 
teristic of  dry  dressings — these  special  agents  enter  no  longer  into  common 
use,  being  employed  only  for  the  special  purposes  befitting  their  utility. 

Oiled  Silk  is  rarely,  indeed,  placed  directly  upon  the  skin  when  em- 
plo3'ed  for  protective  purposes.  Often  rubber  tissue  cut  into  suitable  strips 
is  utilized  in  this  manner,  especially  in  skin  grafting  (page  576)  and  in 
Schede's  method  of  healing  (page  358).  However,  both  of  these  substances 
not  infrequently  cover  and  are  tucked  around  gauze  fabric  already  applied 
to  a  wound  for  purposes  of  cleanliness  and  protection  against  external 
influences. 

At  the  present  time  enterprising  chemists  are  engaged  in  preparing 
for  the  general  market  all  varieties  of  aseptic  and  antiseptic  dressings,  of 
which  the  various  forms  of  gauze  are  the  striking  illustrations.  There 
seems  to  be  no  doubt  that  reputable  producers  of  these  articles  provide 
trustworthy  products  at  a  rate  much  more  satisfactory  in  all  respects  than 
can  be  made  by  the  individual  consumer  and  with  a  great  saving  of  time 
and  annoyance  to  the  latter.  It  is  not  to  be  forgotten  that  sophistication 
of  all  such  products  can  be  readily  practised  and  with  evident  disastrous 


108  OPERATIVE  SURGERY. 

results,  and  therefore  consumers  ought  to  exercise  no  inconsiderable  vigi- 
lance in  securing  efficient  articles. 

Rubber  Dam. — Rubber  dam  is  more  substantial  than  rubber  tissue,  and, 
like  it,  can  be  sterilized  by  soaking  in  a  solution  of  carbolic  acid  or  of 
bichloride  of  mercury.  It,  too,  can  be  used  over  gauze  dressings  to  keep 
them  moistened  when  diffusion  of  the  discharges  through  the  dressings  is 
anticipated  or  is  desirable. 

The  Douching  Apparatus  (Figs.  157,  158). — The  douching  apparatus  is 
easily  made  by  siphoning  the  fluid  from  an  established  or  improvised  re- 
ceptacle by  means  of  a  long,  small  rubber  tube,  at  the  end  of  which  is 
attached  a  glass  or  rubber  nozzle  of  suitable  caliber  to  properly  gauge  the 
amount  of  fluid  employed.  The  flow  can  be  easily  regulated  by  pinching 
the  tube  with  the  thumb  and  finger,  or  by  a  mechanical  attachment  con- 
structed especially  for  this  purpose.  An  ordinary  fountain  syringe  is  a 
durable,  convenient,  and  satisfactory  irrigator  for  most  purposes.  The 
douching  of  wounds  during  operation  is  rarely  practiced  now,  except  for 
the  purpose  of  arresting  hsemorrhage  or  for  the  removal  of  infecting  agents. 

The  Cotton  Batting  Dressing. — Sterilized  cotton  batting  was  much  em- 
ployed formerly  in  contact  with  the  gauze  dressings.  However,  it  is  en- 
tirely inadequate  as  an  absorbent  of  wound  discharges.  The  advent  of 
absorbent,  borated,  salicjdated,  and  other  varieties  of  medicated  cotton,  ab- 
rogated the  use  of  the  former,  except  for  purposes  of  warmth  and  comfort. 

The  Combined  Dressing. — This  form  of  dressing  is  made  by  placing  sev- 
eral layers  of  borated  or  other  variety  of  medicated  cotton  between  two 
layers  of  antiseptic  or  aseptic  gauze.  The  combined  textures  are  then  ster- 
ilized by  heat  and  shaped  to  suit  the  circumstances  of  the  case,  and  placed 
over  the  gauze  already  applied,  and  are  then  confined  in  position  with  asep- 
tic bandages  (Fig.  159). 

In  many  respects  the  "  combined  "  portion  of  the  dressing  of  a  wound 
is  the  most  important  of  the  textile  fabric  contributary  to  the  purpose. 
The  proper  thickness,  the  suitable  outline  and  the  appropriate  extent  of 
this  portion  of  dressing  are  matters  of  significant  fact,  as  bearing  on  the 
comfort  of  the  patient,  the  protection  of  the  wound  and  the  maintenance 
of  accurate  coaptation  of  its  component  parts.  The  application  of  this 
dressing,  and  the  retention  in  place  by  means  of  bandages  or  binders  or  by 
adhesive  strips,  are  matters  of  prime  consequence  in  all  respects.  At  the 
outset  the  dressing  should  be  accurately  and  evenly  applied  and  thus  held 
while  the  retaining  agent  is  similarly  adjusted  for  the  purposes  of  secure 
retention.  A  failure  in  either  of  these  needs  is  quite  certainly  followed 
by  physical  discomfort  and  perhaps  by  surgical  disappointment.  The  width 
of  the  retaining  agent  should  be  proportionate  to  the  thickness  of  the  dress- 
ing and  the  firmness  of  the  required  application.  Unduly  narrow  bandages, 
etc.,  etc.,  are  quite  likely  to  become  cord-like  in  action,  causing  insecurity 
and  discomfort,  only  the  wider  ones  being  in  all  respects  trustworthy. 
Whenever  this  dressing  and  superimposed  fabrics  become  soiled  from  within, 
either  prompt  renewal,  superficial  antisepsis,  with  supplemental  dressing, 
should  be  applied,'  as  the  opportunity  affords. 


THE  TREATMENT  OP   OPERATION-WOUNDS. 


109 


Iodoform. — Iodoform  alone  and  variously  combined  is  largely  employed 
in  surgery.  Iodoform,  when  dissolved  in  ether,  can  be  readily  poured  or 
sprayed  over  the  surface  of  the  operation 
field,  and  the  prompt  evaporation  of  the 
ether  will  leave  the  iodoform  evenly  ap- 
plied thereon.  Only  pure  ether  should  be 
used   for   this  purpose.     If   there    is   any 


Fig.  157.— Douching  bottle. 


Fig.  158. — Extemporized  douching  bottle. 


sign  of  the  liberation  of  iodine  by  the  appearance  of  an  iodine  tint,  the 
ether  was  impure   and  the  solution  should  not  be  used.    Pulverized  iodo- 


FiG.  159. — Dressings  in  position 


form  can  be  well  applied  by  the  agency  of  a  sprinkler  or  blower  (Fig.  160) 
especially  constructed  for  the  purpose.  The  latter,  however,  is  too  fickle 
in  its  action  for  general  use,  and  can  be  best  employed  for  the  introduction 


no 


OPERATIVE  SURGERY. 


of  iodoform  and  other  powders  into  deep  cavities  and  sinuses.     The  amount 
of  iodoform  thus  employed  should  be  small  and  be  evenly  applied.     The 
too  common  practice  of  dusting  the  suture  line  with  iodoform,  without  spe- 
cial indication,  is  a  needless  waste  of  the  drug  and  an  un- 
wise exposure  to  its  poisonous  effects. 

Aristol,  iodol,  and  naphthalin  are  sometimes  employed 
as  substitutes  for  iodoform,  on  account  of  the  objections  to 
the  lattei".     They  are  not,  however,  as  eflBcient  as  iodoform. 

The  Iodoform  Gauze. — Iodoform  gauze  is  now  in  general 
and  established  use.  It  has  thus  far  withstood  the  economic 
assaults  of  the  pharmacists  and  the  ill-judged  prejudice  of 
the  skeptics,  and  become  a  highly  valued  agent  in  advanced 
surgical  technique.  Iodoform  gauze  is  prepared  by  two 
methods — one,  the  ready  method,  which  consists  in  rubbing 
pulverized  iodoform  into  the  meshes  of  moistened  sterilized 
gauze.  This  method  produces  the  most  useful  article,  be- 
cause it  obviates  the  decomposing  influence  of  ether  on  the 
drug,  and  impairs  less  the  capillarity  of  the  textile  fabric ; 
but  for  commercial  purposes  and  hospital  uses  it  is  prepared 
differently. 

At  Bellevue  Hospital  many  kinds  of  dressings  are  used, 
and  of  various  percentage  strength.  It  is  therefore  imprac- 
ticable to  give  all  the  formulas,  but  by  giving  typical  ones, 
chosen  from  those  most  in  use,  the  manner  of  preparation 
will  be  made  sufficiently  clear. 
Dr.  Charles  Eice  said :  "  It  is  proper  to  state  at  the  outset  that  the  per- 
centage strength  of  antiseptic  dressings,  such  as  iodoform  gauze,  bichloride 
gauze,  etc.,  should  refer  to  the  actual  percentage  by  weight  of  the  antiseptic 
agent  contained  in  the  fabric  when  made  as  dry  as  possible.  It  is  not  desira- 
ble completely  to  dry  a  prepared  dressing  which  is  to  be  wetted  or  damp- 
ened before  it  is  used,  as  the  wetting  is  likely  to  wash  out  some  of  the 
antiseptic. 

"  Many  nurses  and  some  manufacturers  of  dressings  call  a  ten-per-cent 
fabric  one  that  has  been  dipped  in  a  ten-per-cent  solution  or  mixture  and 
then  more  or  less  wrung  oat.  The  rule  should  be  to  designate  a  medicated 
fabric  by  the  percentage  of  active  ingredient  it  contains  when  practically 
dry,  and  not  by  the  percentage  strength  of  the  liquid  with  which  it  is 
impregnated. 

"  To  prepare  a  ten-per-cent  iodoform  gauze,  take,  say,  50  parts  by 
weight  of  gauze,  40  parts  of  glycerin,  and  10  of  iodoform.  To  properly 
incorporate  the  latter,  additional  liquid  is  required,  say,  for  instance,  200 
parts  of  alcohol  and  100  parts  of  water.  When  this  gauze  is  finished  and 
dried  the  alcohol  and  water  will  evaporate,  while  the  glycerin  and  iodo- 
form will  remain,  and  the  amount  of  the  latter  will  then  be  ten  per 
cent. 

"  The  Preparation  of  Iodoform  Gauze  of  Different  Strengths. — To  make 
iodoform  gauze  of  the  following  strengths,  use  : 


Fig.  160. 
Iodoform 
sprinkler. 


THE  TREATMENT  OP  OPERATION-WOUNDS. 

Sterilized  absorbent  gauze  (dry) ....   475  grains  ; 

Iodoform The  below-given  amount ; 

Glycerin 1  fluidounce ; 

Alcohol 2  fluidounces. 


Ill 


For 

a  10-pei 

-cent 

gauze 

use 

116 

grains 

of  iodoform. 

20- 

260 

25- 

350 

30- 

450 

40- 

700 

50- 

1,045 

"  Place  the  required  amount  of  iodoform  in  a  suitable  basin  and  add 
to  it  the  glycerin  and  alcohol.  Mix  the  iodoform  thoroughly  with  the  liquid, 
so  that  a  perfectly  homogeneous  mixture  will  result ;  then  incorporate  the 
mixture  with  the  proper  amount  of  gauze  by  repeatedly  rubbing  it  into 
the  texture  and  wringing  out  and  reabsorbing  until  the  mixture  is  entirely 
taken  up  and  uniformly  distributed  in  the  gauze.  Then  spread  the  gauze 
on  a  table  covered  with  an  impervious  fabric  rendered  aseptic  by  wijDing 
with  bichloride  solution  (1  to  1,000) ;  smooth  out  and  then  fold  it  in  a  suit- 
able manner ;  wrap  it  in  sterilized  paraffin  paper,  and  finally  in  sterilized 
oiled  muslin,  and  place  it  in  air-tight  jars. 

"  If  the  amount  of  liquid  for  the  higher  strengths  be  found  insufficient, 
a  little  sterilized  water  may  be  added  to  give  the  mixture  the  proper  de- 
gree of  fluidity. 

"  Tlie  Preparation  of  TMerscVs  Gauze. — Prepare  a  l-in-50  solution  of 
Thiersch's  powder  (which  consists  of  salicylic  acid  1  part,  and  boric  acid  8 
parts)  in  sterilized  water.  To  make  1  quart  of  this  solution,  292  grains 
of  the  powder  will  be  required.  Saturate  the  gauze  with  this  solution  and 
retain  it  therein,  completely  immersed,  for  at  least  twenty-four  hours  ;  then 
wring  it  out  more  or  less  as  may  be  required.  It  is  not  intended  usually 
that  this  gauze  shall  contain  a  definite  percentage  of  the  antiseptics. 

"  The  Preparation  of  Bichloride  Gauze. — To  make  bichloride  gauze  of 
the  following  strengths,  use  : 


Strength. 

1  in  1,000. 

1  in  500. 

1  in  -100. 

Absorbent  gauze  (dry) 

Bichloride  solution  (1  in  1,000) 

Sterilized  water,  enough  to  make 

13  avoir,  ounces 

(10  yards). 
12|  fluidounces. 
32  fluidounces. 

13  avoir,  ounces 

(10  yards). 
25  fluidounces. 
32  fluidounces. 

13  avoir,  ounces 
(10  yards). 

31  fluidounces. 

32  fluidounces. 

"  The  solution  should  be  repeatedly  pressed  out  and  reabsorbed  until  the 
impregnation  is  uniform  and  the  whole  of  the  mixture  is  taken  up  by  the 
gauze.  If  required,  the  gauze  may  be  dried,  best  between  sheets  of  muslin 
in  a  place  free  from  dust.  But  it  is  preferable  to  leave  it  moist,  or  at  least 
not  to  dry  it  completely.  It  should  be  neatly  folded  and  wrapped  in  paraf- 
fin paper  which  has  itself  been  sterilized  by  the  bichloride  solution.  The 
packages  should  be  kept  in  air-tight  receptacles.  Large  museum  jars  of  a 
wide  diameter  are  very  suitable  for  this  purpose. 


112  OPERATIVE  SURGERY. 

"  The  weight  of  absorbent  gauze  per  yard  naturally  varies  with  the 
thickness  and  number  of  the  threads  per  unit  of  surface.  That  which  has 
been  found  to  be  most  suitable  for  general  purposes,  and  is  preferred  at  Belle- 
vue  Hospital,  contains  24  threads  per  inch  of  width  and  28  per  inch  of 
length  ;  average  weight  475  grains  per  square  yard." 

Objections  to  the  Use  of  Iodoform. — The  odor  of  iodoform  is  an  objec- 
tion to  the  use  which  can  not  be  gainsaid.  A  too  free  application  of  the 
drug  to  extended  surfaces,  especially  cranial,  has  been  followed  by  both 
local  and  general  deleterious  and  even  fatal  effects  on  the  patient. 

The  addition  of  tincture  of  musk,  tonka  bean,  or  oil  of  bergamot  will 
lessen  the  offensiveness  of  the  odor.  Iodoform  should  be  used  in  small 
amounts,  especially  in  elderly  persons  and  in  those  affected  with  organic 
heart  or  kidney  disease.  The  needless  or  perfunctory  use  in  any  form  or 
measure  is  to  be  condemned.  The  employment  in  connection  with  firm 
pressure  on  the  wound  and  with  the  use  of  carbolic  acid  is  not  advisable. 
A  small,  rapid  pulse,  attended  with  sleeplessness,  restlessness,  mental  excite- 
ment, etc.,  call  for  the  prompt  removal  of  iodoform  dressing.  Fifteen  grains 
has  caused  transient  delirium  ;  a  drachm  and  more  has  been  applied  without 
special  significance.  The  author  has  not  yet  observed  unfavorable  mani- 
festations from  the  use,  except  in  one  instance,  and  that  in  the  case  of  the 
free  use  to  a  large  cranial  surface. 

Tlie  Peat  Dressing. — Into  a  small  carbolized  gauze  bag  light  peat  or 
turf  is  introduced,  combined  with  two  and  a  half  per  cent  of  iodoform ; 
over  this  a  large  bag  filled  with  carbolized  peat  is  applied,  and  the  whole  is 
bandaged  firmly  in  position.  The  fine  peat  serves  admirably  to  make 
equable  pressure  and  absorb  the  discharges,  and  need  not  be  reapplied  until 
it  has  become  soiled.  Peat  dressing  is  now  rarely  used,  nor  is  there  rea- 
son to  regard  it  with  favor,  except  it  be  first  sterilized  by  heat. 

Coarse  and  fine  jute,  wood-wool,  wood-pulp,  moss,  peat,  and  sawdust, 
can  each  be  made  antiseptic  by  steeping  six  or  eight  hours  in  a  solution  of 
bichloride  of  mercury  (1  to  1,000)  with  five  per  cent  of  glycerin  ;  they  are 
then  wrung  out,  sterilized  with  heat,  after  which  suitable  sized  pads  or 
bags  are  made  with  some  variety  of  antiseptic  gauze. 

Improvised  Antiseptic  mid  Aseptic  Gauze. — Absorbent  gauze  is  made 
antiseptic  by  putting  it  into  a  solution,  bichloride  of  mercury  10  parts,  water 
2,240  parts,  glycerin  250  parts,  and  allowing  it  to  stand  for  ten  or  twelve 
hours,  then  wringing  out  and  sterilizing  by  heat.  If  gauze  be  boiled  for  a 
few  moments  and  the  water  wrung  out,  it  is  then  sufficiently  aseptic  for 
brief  use.  If  it  be  soaked  in  a  strong  antiseptic  solution  for  a  short  time  it 
becomes  antiseptic,  and,  like  the  former,  can  be  employed  pending  the 
prompt  use  of  the  substantial  variety.  Textile  fabrics  and  instruments  can 
be  sterilized — made  aseptic — by  heat  (Fig.  161)  in  any  of  the  many  appa- 
ratus devised  for  the  purpose  and  offered  for  sale,  as  before  stated  (page  52), 
Those  that  combine  moist  heat  and  pressure  influences  are  the  most  effective. 

If  a  specially  prepared  absorbent  gauze,  from  which  all  oily  matters  have 
been  extracted,  is  not  available,  ordinary  bleached  or  unbleached  muslin  may 
be  boiled  in  a  solution  containing  ten  per  cent  of  washing  soda  and  two  per 


THE  TREATMENT  OP  OPERATION-WOUNDS. 


113 


Fig.  161. — A  portable  sterilizer  for  dress- 
ings and  instruments. 


cent  of  caustic  soda,  after  wliicli  it  is  washed  with  water  until  it  no  longer 
affects  red  litmus  paper. 

It  should  not  be  forgotten  that  the  bichloride  of  mercury  is  a  somewhat 
unstable  component,  and  it  therefore  becomes  necessary  to  use  the  freshly 
prepared  combinations.  If  a  small  amount  of  common  salt  be  added  to  the 
solution  its  stability  is  better  maintained. 

Ohjectio7is  to  Bichloride  Gauze. — It  is  well  to  remember  that  bichloride 
gauze  should  not  be  applied  directly  to  the  skin,  especially  that  of  a  child, 
as  it  is  very  liable  to  cause  an  ery- 
thematous irritation. 

The  bichloride  dressing  is  recom- 
mended as  one  possessing  efficiency 
and  safety.  The  soluble  compi'essed 
tablets,  containing  a  definite  amount 
of  bichloride  of  mercury,  are  very 
convenient  for  the  minor  require- 
ments of  general  practice.  They 
should  not,  however,  become  in  any 
way  associated  with  the  compressed 
tablets  employed  for  internal  medi- 
cation, for  obvious  reasons. 

Summary  of  the  Common  Preparations  for  a  Modern  Operation.  The 
Operating  Table. — The  table  should  be  well  covered  with  blankets,  and  by  a 
rubber  cloth  so  arranged,  if  need  be,  that  if  the  table  be  slightly  tilted  all 
the  fluids  employed  will  be  quickly  discharged  into  a  suitable-sized  receptacle 
placed  on  the  floor  (page  41  et  seq.). 

The  Patient. — The  portions  of  the  body  not  to  be  operated  upon  should 
be  carefully  excluded  from  draughts  of  air,  and  also  from  contact  with 
fluids,  by  isolating  them  from  the  immediate  field  of  operation  by  aseptic, 
suitably  arranged  warm  rubber  cloths,  blankets,  and  flannel  garments.  Pre- 
cautions of  this  kind  lessen  the  degree  of  shock  and  the  dangers  of  kidney 
and  pulmonary  complications. 

The  part  to  be  operated  upon.,  together  with  the  contiguous  area,  must 
be  made  entirely  ase23tic  a  few  hours  before  operation  when  practicable  by 
shaving,  soaping,  and  scrubbing  with  a  stiff  aseptic  brush,  after  which  they 
should  be  rinsed  in  alcohol,  or  a  strong  solution  of  carbolic  acid,  or  chlor- 
ine water,  and  wrapped  in  towels  saturated  with  a  strong  antiseptic  fluid. 
A  saturated  ethereal  solution  of  iodoform  may  be  poured  over  the  immedi- 
ate site  of  the  operation,  and  the  antiseptic  wraps  omitted  if  the  operation 
is  to  be  commenced  in  a  few  moments  (page  94  et  seq.). 

The  surrounding  areas,  outside  the  immediate  field  of  the  operation^ 
should  be  isolated  from  it  by  towels  thoroughly  wet  with  strong  anti- 
septic fluid,  and  when  soiled  they  should  be  replaced  promptly  by  clean 
ones.    The  fluids  thus  employed  should  be  warm. 

The  forearms,  hands,  and  nails  of  the  operator,  the  assistants,  and  of 
others  who  are  brought  in  contact  with  the  wound  or  with  the  instruments, 
together  with  the  instruments,  must  be  made  thoroughly  aseptic. 


114  OPERATIVE   SURGERY. 

The  following  is  an  efficient  method  of  securing  proper  cleanliness  of 
the  hands,  etc. : 

The  nails  should  be  cut  short,  and  all  foreign  matter  and  dead  cuticle 
should  be  removed  from  beneath  them  and  from  the  ungui-cutaneous 
creases';  the  forearms  and  hands  (fingers)  should  be  thoroughly  scrubbed 
for  ten  or  fifteen  minutes  with  soap  and  a  stiff  brush ;  the  soap  is  then  care- 
fully washed  off  with  sterilized  hot  water,  and  the  nail-cleaner  employed 
again  as  before ;  a  similar  scrubbing  and  washing  is  repeated,  after  which 
the  extremities  are  thoroughly  rinsed  in  pure  alcohol  and  kept  immersed 
in  a  hot  antiseptic  fluid  or  wrapped  in  antiseptic  towels  or  mittens  until 
the  operation  is  commenced. 

The  following  metliod  of  cleansing  the  hands  is  employed  at  the  Johns 
Hophins  Hospital : 

1.  The  nails  are  kept  short  and  clean. 

2.  The  hands  are  washed  thoroughly  for  ten  minutes  with  soap  and 
water,  the  water  being  as  hot  as  can  be  comfortably  borne,  and  being  fre- 
quently changed.  A  brush  sterilized  by  steam  is  used,  and  any  excess  of 
soap  is  washed  off  with  water. 

3.  The  hands  are  immersed  for  from  one  to  two  minutes  in  a  warm 
saturated  solution  of  permanganate  of  potash. 

4.  They  are  then  placed  in  a  warm  saturated  solution  of  oxalic  acid, 
where  they  remain  until  complete  decolorization  of  the  permanganate 
occurs. 

5.  They  are  next  washed  off  with  a  sterilized  salt  solution  or  water. 

6.  They  are  then  immersed  for  ten  minutes  in  sublimate  solution  (1  to 
1,500). 

The  Nascent  Chlorine  Method. — This  method,  introduced  by  Weir,  is 
practiced  as  follows :  Scrub  the  hands  and  forearms  thoroughly  in  hot  run- 
ning water,  using  green  soap,  and  aiding  the  cleansing  under  and  about  the 
nails  with  a  pointed  wooden  brush. 

Take  about  a  tablespoonful  of  bleaching  powder  (the  ordinary  commer- 
cial chloride  of  lime)  and  about  a  cubic  inch  of  carbonate  of  soda  (common 
washing  soda),  to  which  add  enough  water  to  make  a  thin  paste,  and  rub 
the  whole  about  like  soap.  A  thick  cream  is  formed  which  eniits  free 
chlorine  gas.  Its  application  to  the  skin  surface  at  first  produces  a  sensa- 
tion of  heat,  but  a  little  later  one  of  coolness. 

Continue  rubbing  until  the  little  rough  grains  of  chloride  of  lime  dis- 
appear, or  until  the  creamy  fluid  thickens  into  a  pasty  layer,  or  until 
the  sense  of  coolness  is  felt.  The  procedure  occupies  from  three  to  five 
minutes. 

Wash  the  paste  off  in  sterile  water. 

The  odor  of  chlorine  can  be  removed  by  neutralization  in  a  (sterile)  one- 
fifth-per-cent  solution  of  aqua  ammonia. 

Antiseptic  Gloves. — If  those  who  have  to  do  with  operative  procedures, 
handling  the  dressings,  etc.,  will,  after  the  thorough  cleansing  of  the  hands 
and  arms,  wear  long  canton  flannel  gloves  or  mittens  (Fig.  162)  saturated 
with  a  bichloride  solution,  the  handling  of  miscellaneous  articles  during 


THE  TREATMENT   OF   OPERATION-WOUNDS. 


115 


preparation  of  the  patient  need  cause  no  concern,  especially  if  the  hands  be 
rinsed  again  before  coming  in  direct  contact  with  important  things.  Thin 
rubber  and  cotton  gloves  are  advised  for  the  same  purpose,  and  are  worn  by 
many  surgeons  during  operation.  The  author  uses  thin  rubber  finger  stalls 
instead  of  gloves  (Fig.  163).    They  are  cheap,  serviceable,  cover  the  digits 

well,  and  can  be  promptly  re- 
newed and  replaced  by  others 
when  defective.  At  all  events, 
no  matter  which  be  worn,  the 
hands  should   be  cleansed  with 


Fig.  162.— Canton  flannel  gloves. 


Fig.  163.— Rubber  finger  stalls. 


the  same  degree  of  care  as  without  their  use,  otherwise  the  wound  may  be 
contaminated  by  the  escape  from  within,  through  a  tear  or  puncture  of  the 
rubber,  of  infecting  matter. 

Diagram  of  Arrangements. — The  diagram  of  arrangement  (Treves)  for 
operation  illustrates  a  convenient  method  of  disposal  of  the  different  means 
under  favorable  circumstances.  It  is  rare  indeed  that  this  arrangement  is 
available  or  perhaps  desirable,  except  in  hospital  practice  (Fig.  164). 

The  apparel  of  the  surgeon  and  the  assistants  should  be  clean,  newly 
put  on,  and  free  from  the  insidious  influences  of  communicable  disease.  A 
long  aseptic  rubber  apron  covered  with  a  freshly  sterilized,  short-sleeved, 
white  linen  gown,  both  reaching  to  the  feet,  are  suitable  for  the  surgeon, 
and  can  be  supplemented  by  pinning  in  front  a  sterilized  towel  moistened 
with  the  antiseptic  fluid.  Each  of  the  assistants  should  be  similarly  clothed 
and  cleansed  (Fig.  165).  The  use  of  freshly  laundered  white  linen  overwear 
is  both  cleanly  and  attractive.  The  change  of  the  underwear  is  a  measure 
10 


116 


OPERATIVE  SURGERY. 


that  is  not  always  practiced,  but  it  adds  much,  indeed,  to  the  after-comfort 
of  the  surgeon,  and  not  a  little  to  his  personal  safety  in  the  instances  of 
tedious  effort  in  a  hot  room.    Changeable  water-tight  footwear  is  advised. 


Anaesthetist 


o 

H 

D- 

(D 

03 

TT 

3" 

^ 

g 

g" 

o 

Fig.  164. — Diagram  of  arrangements.    Abdominal  operation. 

Douching. — When  douching  is  practiced  an  attentive  assistant  should 
have  the  care  of  the  douching  fluid,  discharging  it  as  may  be  required  on 


Pig.  165. — a.  The  rubber  glove  with  naked  forearm,  h.  The  rubber  glove,  forearm  lightly 
bandaged  with  aseptic  gauze,  fastened  above  to  the  sleeve  of  the  operating  gown.  The 
gauze  can  be  moistened  with  an  antiseptic  fluid  for  purposes  of  better  apposition  and 
cleanliness,  c.  The  rubber  glove  with  rubber  gauntlet  on  forearm.  This  plan  is  apt 
to  be  uncomfortable  and  cumbersome.     The  writer  practices  the  second  method  (b). 


THE  TREATMENT   OF  OPERATION-WOUNDS. 


117 


the  cut  surfaces  during-  tlic  entire  operation.     This  fluid  may  be  used  either 
hot  (110°  F.  to  120°  F.)  or  cold,  according  to  the  individual  cases. 

As  already  noted,  the  employment  of  free  douching,  or  even  douching 


118  OPERATIVE  SURGERY. 

at  all,  is  practiced  only  to  a  limited  extent  at  the  present  time,  ex- 
cept in  the  instance  of  foul  and  offensive  wounds  or  for  the  arrest  of 
haemorrhage. 

The  Wound. — All  bleeding  points  should  be  tied  with  catgut,  the  wound 
itself  closed  with  catgut,  if  practicable,  and  thoroughly  drained  when  neces- 
sary. If  desirable,  a  small  amount  of  iodoform  may  be  dusted  on  and  close 
the  seat  of  the  wound,  after  which  the  kind  of  dressings  are  applied  that 
have  been  selected  to  complete  the  treatment  and  are  retained  in  place  by 
antiseptic  bandages. 

After  the  Operation. — The  patient  is  wiped  dry,  closely  wrapped,  and 
removed  to  bed,  into  which  bags  or  bottles  of  hot  water  are  introduced  when 
indicated,  so  surrounded  with  flannel  as  to  prevent  burning  the  patient. 
This  precaution  is  of  great  significance,  especially  if  the  patient  be  oblivious 
to  thermal  effects.  Accidental  burning  is  often  the  basis  of  legal  action, 
becoming  a  source  of  great  tribulation  to  all  concerned. 

The  After-treatment. — Absolute  quiet  of  the  patient  and  of  the  part 
bearing  the  wound  is  not  the  least  of  the  elements  necessary  to  secure  a  sat- 
isfactory result.  A  careful  record  of  the  pulse,  temperature,  and  respira- 
tion should  be  kept  (page  11).  If  the  temperature  rises  to  102°  F.,  and 
does  not  become  quite  normal  in  two  or  three  days,  the  dressing  should  be 
removed,  the  drainage  carefully  examined,  and  the  part  inspected,  after 
which,  if  no  contra-indications  exist,  it  is  again  dressed  as  before.  Usually 
the  dressings  are  removed  two  or  three  days  after  the  operation,  and  at 
once  ivhen  the  discharges  from  the  woufid  have  soiled  their  external  surface. 
Furthermore,  care  must  be  taken  that  the  external  dressings  be  kept  closely 
in  contact  with  the  patient  for  a  considerable  distance  from  the  operation- 
wound,  otherwise  unfavorable  influences  may  gain  admission  to  the  wound 
and  prompt  healing  be  thus  prevented.  The  same  antiseptic  precautions 
should  be  employed  with  the  redressing  of  the  wound  as  with  the  operative 
procedure  itself.  Examination  of  the  blood,  urine,  and  lungs  should  be 
made  from  time  to  time  for  obvious  reasons. 

■  The  Open  Dressing. — The  so-called  open  method  of  dressing  consists  in 
washing  the  wound  cavity  with  the  strong  carbolic-acid  solution  at  the  com- 
pletion of  the  operation,  after  which  the  limb  is  placed  upon  a  suitable 
cushion  of  oakum,  and  over  it  is  laid  a  thin  piece  of  gauze,  which  is  kept 
moistened  with  a  solution  of  carbolic  acid.  The  wound  is  washed  two  or 
three  times  daily  by  gentle  irrigation  with  a  carbolic  solution,  after  which 
balsam  of  Peru  is  poured  into  it.  All  the  dressings  are  to  be  kept  clean. 
If  an  antero-posterior  line  of  coaptation  of  the  flaps  is  desired,  they  are 
drawn  together  by  two  or  three  stitches;  otherwise  no  mechanical  agents 
are  applied  to  the  wound.  Before  the  time  of  the  perfection  of  aseptic 
methods  the  open  plan  of  treatment  of  operation-wounds  was  frequently 
practiced;  since  then  it  is  rarely  employed,  except  in  infected  and  slough- 
ing wounds  of  considerable  magnitude.  The  late  Professor  James  E. 
Wood  practiced  this  method  with  eminent  success  in  Bellevue  Hospital 
before  the  time  of  Listerism,  as  the  writer  had,  during  his  interneship, 
abundant  opportunity  to  witness. 


THE  TREATMENT  OF  OPERATION-WOUNDS.  119 


THE    PRECAUTIONARY    REQUIREMENTS. 

Many  of  the  precautionary  requirements  and  their  importance  have  been 
indicated  already  (pages  13  and  14). 

The  Stimulants,  of  which  brandy,  whisky,  champagne,  ammonia,  nitrite 
of  amyl,  digitalis,  strychnin,  etc.,  are  in  common  use,  and  one  or  more 
should  be  at  hand  during  an  operation,  irrespective  of  its  brevity  or  nature. 
Caffein  citrate  hypodermically  and  infusion  of  strong  coffee  by  the  bowels 
are  very  useful  agents. 

For  purposes  of  administration  of  these  agents,  the  hypodermic  and 
Davidson's  syringe  are  most  convenient.  Under  no  circumstance  should 
fluids  be  administered  by  the  mouth,  if  the  patient  be  unconscious,  except 
by  the  medium  of  a  stomach  tube. 

The  Tongue  Forceps  and  Mouth  Gag. — The  importance  of  these  imple- 
ments has  been  sufficiently  emphasized  already  to  render  the  necessity  for 
their  presence  evident   (page  13). 

The  Electric  Battery. — The  battery  must  be  at  hand  when  the  nature  of 
the  operation  or  condition  of  the  patient  might  give  rise  to  the  failure  of 
the  circulatory  or  respiratory  powers. 

The  Tracheotomy  Tube. — Although  the  tracheotomy  tube  is  not  neces- 
sary to  the  performance  of  tracheotomy  or  laryngotomy  when  indications 
suddenly  arise  calling  for  either,  yet  it  is  better  to  be  provided  with  one. 
The  surgeon  must  not  overlook  the  fact  that  the  death  of  a  patient  due  to 
the  absence  of  a  tube,  or  to  the  loss  of  time  consumed  in  seeking  for  one,  is 
unpardonable. 

The  Elastic  Bandages. — Elastic  bandages  are  not  only  important  in  pre- 
venting the  direct  loss  of  blood,  but,  as  heretofore  stated  (page  69),  very 
important  when  applied  to  the  limbs  for  the  purpose  of  forcing  the  blood 
contained  in  them  into  the  trunk,  as  in  cases  of  impending  death  from  shock 
due  to  the  loss  of  blood.  They  are,  in  our  opinion,  of  great  practical  utility 
for  immediate  use  in  such  cases.  They  will  certainly  bridge  over  the  inter- 
val of  time  necessary  to  prepare  for  transfusion  better  than  any  other  ex- 
pedient. 

Transfusion. — If  the  operation  be  of  such  a  nature  that  great  loss  of 
blood  is  liable  to  happen,  arrangements  should  be  perfected  for  the  rapid 
performance  of  this  measure  by  the  utilization  of  blood  or,  better  still,  the 
saline  solution  (Transfusion,  page  220  et  seq.). 

Artificial  Bespiration. — No  one  can  be  safely  intrusted  to  administer  an 
anagsthetic  or  to  attempt  any  operative  procedure  who  is  not  familiar  with 
the  manipulations  necessary  for  the  proper  performance  of  this  means  of 
resuscitation  (pages  18,  19).  It  is,  in  fact,  the  only  one  of  the  require- 
ments which  should  be  continuously  employed  until  the  safety  of  the  patient 
is  assured,  or  until  death  is  an  established  fact. 

Finally,  a  surgeon  should  not  begin  an  operation  without  having  care- 
fully rehearsed  its  various  steps  in  his  mind  (page  10),  together  with  the 
possible  complications  that  may  arise  and  the  best  meansof  combating  them. 

Precautions  of  this  kind  serve  to  distinguish  the  careful  and  conscien- 


120  OPERATIVE  SURGERY. 

tious  surgeon,  who  places  a  proper  value  upon  human  life,  and  a  just  pro- 
fessional reputation,  from  the  one  who  operates  only  because  the  opportu- 
nity is  offered,  and  considers  the  details  tedious  or  worthless  because  he  has 
not  had  sufficient  patience  or  faith  to  practice  them.  Such  as  he  trust  to 
luck,  and  often  attribute  the  result  when  the  patient  succumbs  to  inscrutable 
Providence. 

THE    SPECIAL   EMERGENCIES. 

While  the  scope  of  this  work  will  not  admit  of  an  extended  considera- 
tion of  these  emergencies,  still  it  is  the  author's  earnest  desire  to  so  empha- 
size their  importance,  that  those  desiring  additional  information  will  seek 
it  from  other  and  more  extended  sources.  Unexpected  emergencies  not 
infrequently  occur  during  the  course  of  an  operation,  even  though  they 
be  of  a  minor  character.  The  anesthetic  given  to  relieve  pain  may  from 
unknown  reasons  prove  a  treacherous  ally,  and  by  an  unexpected  influence 
surround  the  case  with  greater  gravity  than  that  of  the  condition  demand- 
ing the  operation.  This  emergency,  together  with  the  suffocation  that  may 
be  caused  by  the  solid  contents  of  an  incautiously  fed  stomach,  or  one  with 
tardy  digestion,  finding  their  way  into  the  air  passages,  has  been  quite  fully 
considered  in  the  preceding  pages. 

Shock. — The  symptoms  of  this  important  nervous  state  especially  de- 
mand a  careful  study  on  the  part  of  those  who  contemplate  practicing  sur- 
gery. Shock  may  exist  before,  occur  during,  or  follow  an  operation,  and  in 
either  instance  may  depend  on  loss  of  blood,  on  physical  injury,  profound 
emotion,  or  on  all  combined.  Shock  may  be  slight  in  degree  or  be  charac- 
terized by  syncope,  may  be  attended  or  followed  by  collapse.  Also  depres- 
sion of  the  vital  forces  is  caused  by  profound  mental  emotion,  and  in  all 
instances  shock  is  the  outcome  of  exhaustion  of  or  hindrance  of  the  vaso- 
motor function.  In  sliocTc,  the  blood  accumulates  in  the  veins,  especially 
those  of  the  abdominal  system,  leaving  the  arteries  and  capillaries  corre- 
spondingly depleted. 

Collapse,  according  to  Crile,  is  a  manifestation  due  to  hindrance  or 
inhibition  of  the  vaso-motor  center,  and  shock  is  dependent  on  exhaustion 
of  this  center.  However,  both  may  be  present  at  the  same  time.  Obviously, 
shock  varies  in  intensity  and  duration,  according  to  the  degree  of  injury, 
the  loss  of  blood,  the  sex  and  personal  characteristics  of  the  patient,  and 
the  nature  and  extent  of  already  existing  disease.  Injury  of  some  special 
organs,  as  the  brain,  thoracic  and  abdominal  viscera,  and  of  the  testicle, 
cause  profounder  shock  than  attends  injuries  of  a  similar  degree  of  other 
tissues.  Direct  stimulation  of  the  pneumogastric  and  reflex  stimulation  of 
the  nuclei  arrests  cardiac  action,  causing  death  by  inhibition. 

The  prevention  of  shock  relates  to  a  careful  study  of  the  patient's  com- 
plicating conditions,  and  the  employment  of  measures  to  obviate  these 
adverse  influences.  The  length  of  time  the  patient  is  exposed  to  operative 
measures,  to  the  effects  of  ether,  and  of  wet  and  cold,  and  the  amount  of 
haemorrhage  exercise  a  potent  effect,  suggesting  that  the  procedure  be  com- 
pleted as  soon  as  practicable  with  a  minimum  amount  of  ether,  with  warm. 


THE  TREATMENT  OF  OPERATION-WOUNDS.  121 

dry  surface,  and  prompt  arrest  of  bleeding.  For  an  operator  to  be  obliged 
to  wait  for  an  assistant  to  tliread  needles,  cut  ligatures,  and  attend  to  other 
various  details,  thus  consuming  time  important  for  the  patient's  welfare,  is 
conclusive  evidence  of  a  serious  lack  of  foresight,  which  too  often  contrib- 
utes its  influence  to  disastrous  results. 

Cocaine  infiltration  of  the  large  nerves  of  a  limb  in  amputation  lessens 
and  even  prevents  shock  (page  35). 

Shock  due  to  the  loss  of  blood  has  characteristics  somewhat  distinctive 
from  that  dependent  on  mutilation  of  the  soft  parts.  In  the  former,  the 
cold,  clammy  surface,  feeble,  fluttering  pulse,  extreme  pallor  of  the  mucous 
surfaces,  great  restlessness,  and  sighing  respiration  are  especially  promi- 
nent. 

The  Treatment  of  Shock. — The  treatment  of  shock  is  modified  by  the 
degree  and  by  the  cause  of  the  depression.  In  an  ordinary  degree  of  shock, 
lowering  of  the  head,  admission  of  fresh  air,  the  application  to  the  surface 
of  bottles  and  bags  oi  hot  water,  and  hot  blankets  may  suffice.  Mustard 
sinapisms  to  the  epigastric,  the  cardiac,  and  to  the  dorsal  regions  of  the 
hands  and  feet,  collectively  or  singly,  will  contribute  a  restorative  effect. 
High  enemata  of  hot  normal  saline  solution,  hot  infusion  of  coffee,  and 
perhaps  of  whiskey,  are  advantageous  aids.  The  inhalation  of  oxygen,  the 
subcutaneous  injection,  according  to  circumstances,  of  fifteen  or  twenty 
drops  of  sterilized  oil  of  camphor  (Senn),  and  bandaging  of  the  extremities, 
are  commended  in  severe  cases;  also  abdominal  massage,  artificial  respira- 
tion and  diaphragmatic  stimulation  (galvanic)  can  be  utilized  in  similar 
cases.  The  injection  of  the  hot  saline  solution  into  the  cellular  tissue  of 
the  thigh,  breast,  and  intra-scapular  region  (hypodermoclysis,  page  222), 


^ 
/^-'r, 


'Mj, 


UuvV 


Fig.  167. — Crile's  inflated  rubber  suit  for  treatment  of  shock. 

into  the  bowel  (enteroclysis,  page  222),  and  into  the  venous  system  (intra- 
venous injection,  page  220),  are  each  of  signal  importance  in  cases  of  severe 
shock,  especially  when  due  to  loss  of  blood. 

In  pure  shock  (diminution  of  blood  pressure  due  to  exhaustion  of  vaso- 
motor center),  according  to  Crile,  the  peripheral  capillary  exhaustion  due 
to  vaso-motor  failure  is  best  met  by  agents  that  create  peripheral  resistance. 
For  that  purpose  medicinally  Crile  commends  the  slow  intravenous  intro- 


122  OPERATIVE  SURGERY. 

duction  of  a  fluid  composed  of  a  teaspoonful  of  a  solution  (1  to  1,000) 
of  adrenalin  and  a  quart  of  hot  normal  saline  solution.  To  meet  the  same 
indication  mechanically  Crile  applies  to  the  surface  of  the  patient's  body 
"  a  rubber  suit  made  of  a  double  layer  of  especially  constructed  rubber, 
which,  when  inflated,  gives  a  uniform  pressure  (Fig.  167)  upon  the  sur- 
face, producing  an  artificial  peripheral  resistance."  The  pressure  is  varied 
with  the  demands  of  the  case. 

In  collapse  the  fall  of  the  blood  pressure  is  sudden,  due  to  profuse 
haemorrhage,  injuries  of  the  vaso-motor  center  or  to  cardiac  failure,  "  repre- 
senting suspension  of  function  rather  than  exhaustion  of  centers  "  (Crile). 
For  this  condition  strychnia,  ammonia,  etc.,  may  be  employed  combined 
with  artificial  respiration,  rhythmic  pressure  upon  the  prsecordial  region, 
lowering  and  raising  the  head,  followed  by  the  hot  saline  infusion  with  or 
without  adrenalin,  as  the  severity  of  the  case  demands. 

The  Comments. — In  deepening  shock  cease  operation  at  once,  except 
dependent  on  cause  demanding  continuance  to  save  the  life  of  the  patient. 
When  lowering  of  head  causes  cyanosis,  reverse  the  movement.  The  arterial 
pressure  incident  to  varying  arterial  tension  can  be  quite  well  estimated  by 
educated  touch,  but  instruments  of  precision  (Fig.  168)  are  better  for  the 
purpose,  and  afford  the  opportunity  of  establishing  a  definite  record  of 
measurement.  Ether  should  be  carefully  administered  in  cases  of  shock, 
and  not  at  all  hypodermically  when  its  inhalation  causes  depression,  for  an 
obvious  reason.  The  use  of  strychnia,  digitalis,  amyl  nitrite,  hypodermic- 
ally  or  otherwise,  without  well-considered  therapeutic  differentiation  of 
need  should  be  carefully  avoided.  The  careless  and  seemingly  even  guarded 
use  of  bags  and  bottles  of  hot  water  are  so  frequently  attended  with  grievous 
burns  as  to  require  the  most  careful  surveillance  in  their  application. 

Air  in  the  Veins. — This  accident  is  associated  with  operations  upon  the 
portions  of  the  body  where  the  venous  circulation  is  markedly  influenced 
by  the  force  of  aspiration,  as  in  the  regions  of  the  neck,  chest,  and  axillge. 
Here,  if  a  vein  that  is  connected  with  a  morbid  growth  be  nicked  while  on 
the  stretch,  or  otherwise  divided,  it  m.ay  open  sufficiently  to  admit  the  en- 
trance of  air,  on  account  of  the  tension  of  its  walls  and  the  influence  of  the 
respiratory  force.  The  air  gains  the  right  side  of  the  heart,  causing  dis- 
tention of  that  cavity  with  frothy  blood,  obstructing  more  or  less  the 
pulmonary  circulation.  If  the  wound  is  filled  with  blood  or  fluid  this 
accident  will  not  occur,  as  the  fluid  will  prevent  the  entrance  of  air  into 
the  vessel. 

The  Symptoms. — The  local  symptoms  are  a  bubbling  or  hissing  sound 
at  the  seat  of  the  haemorrhage,  sometimes  attended  with  air-bubbles.  The 
patient  becomes  pallid,  with  anxious  facies,  labored  breathing,  and  livid 
lips,  attended  with  a  churning  sound  on  cardiac  contraction.  Eapid  insen- 
sibility or  convulsions  may  be  the  principal  features.  Sudden  death  not 
infrequently  occurs. 

The  Treatment. — The  treatment  should  be  quick  and  decisive.  Close 
the  opening  at  once  with  the  finger  or  sponge,  and  make  forcible  pressure  on 
the  thorax  with  the  next  expiratory  movement,  raising  the  finger  from  the 


THE   TREATMENT  OF  OPERATION-WOUNDS. 


123 


vessel  to  ijcrmit  the  air  to  escape.     Close  the  vessel  again  and  repeat  the 
thoracic  compression,  if  need  be. 

Catheterization  of  the  wounded  vein  and  aspiration  of  the  heart  by 
passing  the  needle  through  the  fourth  intercostal  space  near  the  left  side 


Fiu.  168.— Janeway's  portable  sphygmoiuauomeler. 

A.  Jointed  u-tube  manometer,  which  folds  into  case.  B.  Compressing  armlet  (12  cm. 
inside  width).  C.  Politzer  inflator.  D.  T-tube  connecting  A.  B.  and  C.  tor  carry- 
ing, upper  joint  of  manometer  fits  in  rings  to  right,  scale  slides  down  eork^  cioses 
open  end  of  manometer,  rubber  joint  G  is  automatically  compressed  by  block  in 
bottom  of  case,  and  spring  H  holds  stop-cock  E. 

of  the  sternum  (see  Heart,  Vol.  II)  are  permissible  in  desperate  cases,  and 
based  upon  the  idea  of  withdrawing  frotiiy  blood  and  tluis  relieving  the 
obstruction.     Consequently  the  effort  should  cease  at  once  with  the  escape 


124:  OPERATIVE  SURaERY. 

of  clear  blood.  However,  in  this  class  of  cases  death  usually  forestalls  the 
efEort  of  relief. 

Kemp  recommends  artificial  respiration  and  hot  saline  infusion  in  these 
accidents. 

The  Preventive  Treatme?it. — The  preventive  treatment  consists  in  the 
adoption  of  such  measures  as  shall  prevent  the  entrance  of  air:  1.  Pressure 
upon  the  vein  by  the  fingers  at  its  proximal  portion  during  an  op'eration.  2. 
iivoid  making  incisions  during  inspiration,  especially  in  the  vicinity  of 
large  veins,  and  when  the  veins  are  held  open  by  disease  of  their  coats  or  of 
the  surrounding  tissues.  3.  If  a  vein  be  cut,  compress  it  at  once  and  then 
ligature  it.  4.  Keep  the  field  of  operation  well  covered  with  fluid,  if  pos- 
sible. 

If  the  means  here  given  be  carefully  employed,  the  fear  of  this  compli- 
cation need  not  oppress  the  surgeon. 


CHAPTER  IV. 

TEE  LIGATURE   OF  ARTERIES.— GENERAL    CONSIDERATIONS. 

Arteries  are  ligatured  in  their  continuity  and  at  their  divided  extremi- 
ties. Under  this  heading,  however,  will  be  considered  the  ligaturing  of 
arteries  in  their  continuity  only.  Nearly  all  arteries  to  which  ligatures  are 
thus  applied  can,  from  their  association  with  the  soft  and  hard  parts,  be  said 
to  possess  certain  guides,  which,  when  carefully  adhered  to,  indicate  with 
precision  the  normal  position  of  the  vessel  beneath  the  surface. 

The  guides  to  arteries  in  the  living  subject  are  practically  six  in  number : 
1.  The  linear  guide.  2.  The  muscular  guide.  3.  The  bony  guide.  4.  The 
contiguous  anatomical  guide.     5.  The  pulsation.     6.  The  color  of  the  vessels. 

The  linear  guide  to  an  artery  is  a  line  drawn  upon  the  external  surface 
so  as  to  correspond  with  the  established  course  of  the  vessel  beneath.  The 
extremities  of  the  line  are  usually  indicated  by  the  relation  which  the  vessel 
bears  to  fixed  bony  prominences. 

The  muscular  guide  is  one  based  upon  the  relation  which  the  vessel 
bears  to  some  portion  of  a  well-developed  superficial  or  deep  muscle,  the 
outline  of  which  can  be  quite  readily  traced  if  the  muscle  be  placed  upon 
the  stretch.  If  the  border  of  a  muscle  be  given  as  the  guide,  it  must  not  be 
forgotten  that,  in  case  the  muscle  be  unusually  developed,  or  have  a  broader 
origin  or  insertion  than  common,  it  will  overlap  the  vessel,  and  thus  may 
lead  the  surgeon  astray.  Under  these  circumstances  attention  must  be 
directed  unerringly  to  the  contiguous  anatomical  guides,  which  include  the 
relation  that  a  vessel  bears  to  the  immediate  surrounding  parts,  and,  when 
taken  in  connection  with  the  pulsation,  lead  directly  to  it.  The  contiguous 
guides  to  an  artery  may  be  muscular,  if  a  muscle  be  ascertained  to  bear 
an  established  relation  to  it ;  or  hony,  when  a  bony  prominence  is  in  close 
contact  with  it ;  or  nervous,  when  a  certain  nerve  is  known  to  lie  in  a  defi- 
nite relation  to  it ;  or  vascular,  when  vessels  of  an  established  arrangement 
are  associated  with  it ;  and,  finally,  the  sheath  of  the  vessel  itself  becomes 
a  valuable  guide  when  it  is  considered  in  connection  with  the  other  guides. 
Some  of  the  large  vessels,  of  which  the  common  carotid  and  femoral  arteries 
are  the  most  striking  examples,  have  well-developed  sheaths,  while  the  smaller 
arteries  are  surrounded  by  a  greater  or  less  amount  of  areolar  tissue  only. 
The  larger  arteries,  as  the  popliteal,  femoral,  and  subclavian,  are  each  ac- 
companied by  a  single  vein  which  commonly  runs  in  a  definite  relation  with 
them.  The  smaller  arteries,  especially  those  of  the  extremities,  are  attended 
by  satellite  veins,  two  in  number,  known  as  vencB  comites ;  however,  this 

135 


126 


OPERATIVE  SURGERY. 


Fig.  169. — Making  primary  incision. 


arrangement  is  not  invariable,  since  three  or  more  of  these  veins  are  often 
seen.  The  vessels  are  distinguished  from  each  other  by  the  light  or  pinhish 
color  of  the  arteries  and  the  dark  color  of  the  veins.  If  three  vessels  are 
seen,  the  middle  one  is  almost  certain  to  be  the  artery ;  if  more  than  three 

exist,  the  third  vein  usually 
rests  upon  the  artery.  If 
pressure  be  made  upon 
these  vessels,  the  veins  be- 
come distended  and  the 
artery  collapsed  on  the 
distal  side  of  pressure.  If 
to  these  facts  be  now 
added  the  pulsation  of 
the  artery,  its  location  is 
assured.  However,  the 
operator .  who  relies  exclu- 
sively upon  the  arterial  impulse  as  a  guide  may  be  led  astray  by  the  trans- 
mitted pulsations  of  contiguous  vessels,  or  by  the  movements  of  parts  near 
to  which  the  artery  is  located. 
Having  settled  the  details 
of  the  operation,  the  portion 
of  the  body  in  which  the 
vessel  is  situated  is  properly 
prepared  and  so  placed  as  to 
afford  room  and  the  best  pos- 
sible light  for  the  procedure. 
The  part  of  the  vessel  is  then  selected  for  ligature  at  which  the  surgeon 
feels  best  assured  of  the  absence  of  branches  of  sufficient  size  to  interfere 
with  formation  of  the  internal   clot.     The  primary  incision  is  made,  if 

possible,  so  that  the  center 
shall  correspond  to  the  por- 
tion of  the  vessel  to  which 
the  ligature  is  to  be  applied. 
The  length  of  the  primary  in- 
cision will  depend  upon  the 
depth  of  the  vessel,  and  should 
always  be  of  sufficient  extent 
to  afford  easy  access  to  it.  If 
the  thumb  and  finger  be  em- 
ployed to  make  the  integu- 
ment tense  and  steady  at  the 
time  of  the  incision,  great 
care  must  be  taken  that  the 
tension  be  equal  on  the  respective  sides  (Fig.  169),  otherwise  the  incision 
will  fall  outside  the  line  of  the  vessel  after  the  tissues  are  released,  which,  if 
unheeded,  will  lead  the  surgeon  astray ;  besides,  the  consequent  irregularity 
of  the  wound  will  interfere  with  the  necessary  space  and  light  as  well  as 


Fig.  170. — Appruaeii  to  vessel. 


Fig.  171. — Opening  the  sheath. 


THE  LIGATURE  OP  ARTERIES. 


1^1 


with  the  drainage  of  the  part.  The  external  incision  should  be  made  with 
one  sweep  of  the  knife  rather  than  l)y  repeated  cuts,  which  tend  to  chop 
the  tissues,  thus  lessening  the  prospect  of  union  by  first  intention. 

The  fascia  is  divided  in  a  similar  manner.    The  tissues  beneath  the  fascia 
are  gentlv  separated  by  the  fingers  or  handle  of  the  scalpel,  using  the  cutting 


edge  only  when  necessary,  until  the  sheath  of  the  vessel  is  reached.  The 
nearer  the  approach  to  the  vessel  the  shorter  should  be  the  line  of  the  sepa- 
ration of  the  tissues,  so  that  when  the  vessel  is  reached  the  outline  of  the 
wound  will  resemble  somewhat  an  inverted  triangle,  with  its  apex  corre- 
sponding to  the  sheath  of  the  artery  ( Fig.  170) .  When  the  sheath  is  reached 
a  small  opening  is  made  into  it — about  one  fourth  of  an  inch  being  ample — 
of  sufficient  size  to  pass  the  needle  with  ease.  This  opening  is  made  by  pick- 
ing up  the  sheath  or  condensed  tissue  with  the  thumb  forceps,  carefully 
cutting  from  it  a  buttonhole-shaped  piece  of  a  suitable  size  (Fig.  171). 

The  borders  of  the  opening  in  the  sheath  are  then  separately  raised,  to 
enable  the  operator  to  ascertain  if  deeper  tissues  still  surround  the  vessel; 
if  so,  the}^,  too,  should  be  incised  in  a  similar  manner.  When  the  peculiar 
pinkish- white  appearance  of  the  coats  of  the  artery  are  seen,  the  side  of  the 

cut  in  the  sheath  nearest 

to   the   contiguous  vein, 

or  other  important  struc- 
ture,  should  be  grasped 

and  raised  by  the  forceps 

(Fig.    172,   a),   and   the 

aneurism  needle,   armed 

with   a   ligature   or  not, 

carefully  passed  from  the 

point  of  greatest  danger 
around  the  vessel,  while  the  opposite  side  of  the  opening  in  the  sheath  is 
grasped  (6)  to  facilitate  the  exit  of  the  advancing  end  of  the  instrument. 
When  the  needle  is  armed,  a  bent  probe  can  be  used  to  prepare  the  way  (Fig. 
173).     If  the  location  of  the  vessel  will  permit,  the  needle  may  be  intro- 


FiG.  17o. 
Passing  the  probe. 


Fig.  174 


curved  needle. 


128 


OPERATIVE  SURGERY. 


duced  armed  (Fig.  174),  and  when  the  advancing  ligature  appears  at  the 
opposite  side  of  the  vessel  it  is  seized  and  one  end  brought  through  by 
forceps  and  the  other  left  in  position  by  withdrawal  of  the  needle.  Less 
disturbance  of  the  soft  parts  attends  the  placing  of  a  ligature  when  the 


I- 1 


// 


*  ,-3i 


'-Nv 


Fig.  175. — Instruments  for  ligature  of  arteries. 

a.  Scalpels,  b,  c.  Forceps,  d.  Forcipressure.  e.  Traction  loops.  /.  Ligature,  g.  Tenac- 
ulum, h.  Grooved  director,  i,  k,  I.  Aneurism  needles,  m.  Bent  probe,  n,  o,  p. 
Common  retractors. 


THE   LIGATURE   OF  ARTERIES. 


129 


needle  is  introduced  unarmed  and  when  the  way  has  been  prepared  already 
by  the  probe.  If  all  doubts  be  settled  as  to  the  identity  of  the  vessel,  the 
ligature  is  tied  by  either  the  surgeon's  or  the  reef  knot,  l)oth  ends  cut 
short,  and  the  wound  closed  and  dressed  in  the  usual  manner. 

The  kind  of  Instruments  required  to  Ligature  Arteries  in  their  Continuity 
(Fig.  175). — Ordinary  scalpels  {a),  common  thumb  and  mouse-tooth 
forceps  (&,  c),  forcipressure  {d),  traction  loops  (e),  tenaculum  (g),  grooved 
directors  {h,  i),  aneurism  needles  (1-,  I),  probe  {m),  retractors  {n,  o,  p),  and 
ligatures  (/) .  The  number  of  each  of  the  respective  agents  is  regulated  by 
the  demands  of  individual  cases.  The  need  for  blunt  hooks,  artificial  light, 
and  specially  designed  instruments  will  be  self-evident  as  circumstances  arise. 

The  Retractors  vary  in  size  and  shape.  The  ones  recommended  by 
Professors  Mott  (o,  p.  Fig.  175)  and  Parker  {n,  Fig.  175)  are  appropriate 


Fig.  176. — Extemporized  retractors. 


Fig.  177. 
Student's  needle. 


for  all  common  purposes.  If  neither  be  at  hand,  others 
can  be  extemporized  by  bending  the  handle  of  a  common 
tablespoon  or  the  tines  of  a  fork  to  the  necessary  angle 
(Fig.  176). 

The  Aneurism  Needle. — The  aneurism  needles  differ  in 
size,  shape,  and  arrangement.  The  simplest  form  is  com- 
bined with  a  director.  Also  one  with  a  lateral  curvature 
may  be  employed  (t,  /,  Fig.  175)  ;  another  with  adjustable 
points  for  the  purpose  of  securing  deep-seated  vessels.  These 
points  must  be  securely  screwed  in  position,  else  the  turning 
of  the  instrument,  often  necessary  in  passing  it,  may  loosen  them,  causing 
the  instrument  to  become  a  source  of  annoyance  instead  of  an  advantage 
10* 


Fig.  178. 

Mott's  aneurism 

needle. 


130 


OPERATIVE  SURGERY. 


(Fig.  178).  In  Fig.  177  is  a  representation  of  the  safest  needle  with  mov- 
able points  now  in  use.  It  is  known  as  the  "  Movable  Immovable  Aneurism 
Needle,"  and  also  as  the  "  Student's  "  Needle.  It  was  devised  by  Dr.  S.  W. 
Fletcher,  of  Pepperell,  Mass.,  while  a  student ;  hence  the  name  sometimes 
given  to  it. 


THE    LIGATURE    OF   SPECIAL   ARTERIES. 

Ligature  of  the  Abdominal  Aorta. — The  abdominal  aorta  can  be  liga- 
tured at  its  lower  two  inches — that  is,  below  the  origin  of  the  inferior 
mesenteric — by  either  of  two  or  three  methods. 

The  Contiguous  Anatomy. — In  front  lie  the  omentum,  intestines,  peri- 
tonaeum, sympathetic  nerves,  and  mesentery ;  lehind  lie  the  left  lumbar 
veins,  receptaculum  chyli,  thoracic  duct,  and  vertebral  column  ;  at  the  right 
lie  the  inferior  vena  cava,  vena  azygos,  and  thoracic  duct ;  at  the  left  no  im- 
portant structures  are  suffi- 
mansPEmmcw  'Hi  i^'"|i|iH  ^\  WWim^"^ ' ^"-  ciently  near  to  be  injured 

with  the  exercise  of  reason- 
able caution  (Fig.  179). 

The  linear  guide  to  the 
vessel  is  the  linea  alba. 

The  vessel  at  this  situa- 
tion has  no  practical  mus- 
cular or  hony  guide. 

The  Operation.  First 
Method  (Cooper).  —  With 
the  patient  on  the  back 
and  the  legs  flexed,  make 
a  straight  incision  four  or 
five  inches  in  length  to  the 
left  of  the  umbilicus — to 
which  the  center  of  the  in- 
cision may  correspond  (Fig.  180,  a) — through  the  various  tissues,  compris- 
ing the  abdominal  wall  at  this  point,  to  the  peritonaeum,  dividing  each  care- 
fully. Check  all  oozing,  and  cautiously  incise  the  peritonaeum,  securing  its 
borders  with  long  traction  loops  (see  Fig.  51)  to  prevent  them  from  retreat- 
ing outward  behind  the  abdominal  muscles. 

Turn  the  patient  toward  the  right,  or  tilt  the  table  in  that  direction, 
thereby  aiding  the  displacement  of  the  intestines  to  that  side;  locate  the 
vessel  with  the  finger  and  carefully  cut  through  the  peritonaeum  cover- 
ing the  vessel  at  the  left  side,  pass  the  needle  away  from  the  vena  cava 
and  from  behind  forward,  closely  hugging  the  aorta  and  carefully  avoiding 
the  sympathetic  nerves  and  inferior  vena  cava.  This  operation  should  be 
done  with  strict  antiseptic  precautions.  If  it  be  possible,  the  temperature  of 
the  operating-room  should  be  85°  F.  at  least,  and  the  room  should  have  been 
thoroughly  cleansed.  If  it  be  necessary  to  remove  any  of  the  intestines 
from  the  abdominal  cavity,  they  must  be  wrapped  after  removal  in  aseptic 


Fig. 


m^mTCRYS:  VEIN. 

^  1\  CATCRNAL  ILIAC 

i\ARTERY  SiVEIN. 

^V^ INTERNAL  ILIAC 

\^W  AFimRY  &  VEIN. 

179. — Relations  of  large  vessels  to  each  other. 


THE  LIGATURE  OF  ARTERIES. 


131 


gauze  well  wet  with  the  hot  saline  solution.  The  Trendclenlnirg  position 
may  be  employed  with  advantage. 

Second  Method  (Murray). — The  second  method  leads  to  the  vessel  with- 
out opening  into  the  alxlominal  cavity. 

The  Linear  Guide  to  tlie  Operation. — A  line  drawn  from  the  apex  of 
the  tenth  rib  downward  and  forward  to  within  about  one  inch  of  the  ante- 
rior superior  spine  of  the  ilium  (Fig.  181,  ?^)  is  a  proper  linear  guide. 


i'V 


Fig.  180. — Linear  guides. 
a.  For  ligature  of  aorta  (Cooper),     i.  For 
ligature  of  common  iliac  (Crampton). 

c.  For  ligature  of  common  iliac  (McKee). 

d.  For  ligature  of  deep  epigastric  and 
circumflex  iliac  artei'ies.  e,  e,  e.  Inci- 
sions in  upper,  lower,  and  lateral 
regions.  /.  Carotid  curved  incision  in 
median  line. 


Fig.  181. — Linear  guides. 
,  For  ligature  of  common  iliac  (transperi- 
toneal), h.  For  ligature  of  common 
iliac  (extra  peritoneal),  c.  For  ligature 
of  common  iliac  through  semilunar  line 
(transperitoneal),  e.  For  same  through 
fibers  of  rectus,  d.  For  ligature  of  ex- 
ternal iliac.  /.  For  ligature  of  same. 
g.  For  ligature  of  common  femoral,  h. 
Incision  through  outer  border  of  rectus 
for  opening  abdomen  at  that  situation. 

The  Contiguous  Anatomy. — The  ureter  lies  to  the  outer  side.  In  other  re- 
spects the  importance  of  the  relations  of  the  vessel  is  alike  in  both  methods. 

The  Operation. — Divide  the  various  tissues  comprising  the  abdominal 
wall  on  a  grooved  director  down  to  the  peritonaBum;  turn  the  body  to  the 
opposite  side;  insert  the  hand  into  the  wound;  separate  the  peritongeum 
and  raise  it  along  with  the  intestines  and  ureter  carefully  upward  and  in- 
ward, thus  readily  exposing  the  aorta  to  view.  The  aorta  is  then  raised 
with  the  finger  or  a  blunt  instrument  and  the  ligature  passed  as  before. 
The  aorta  can  be  reached  through  an  incision  extending  from  the  end  of 
the  last  rib  to  the  anterior  superior  spinous  process  of  the  ilium. 

The  Results.- — The  aorta  has  been  ligatured  fourteen  times,  and  in 
every  instance  death  occurred  within  from  three  hours  to  forty-eight  days 
after  the  operation.    Ten  were  ligatured  before  the  aseptic  period. 

Ligature  of  the  Common  Iliac  Arteries. — The  common  iliac  arteries  are 
ligatured  with  greater  confidence  since  the  advent  of  aseptic  procedure. 

The  Anatomical  Points. — The  common  iliac  arteries  average  about  two 
inches  in  length,  and  should  be  ligatured  as  near  the  middle  as  possible. 
They  commonly  begin  at  the  left  of  the  middle  of  the  body  of  the  fourtli 


13^ 


OPERATIVE  SURGEHY. 


lumbar  vertebra,  and  diverging  pass  downward  and  outward  to  the  sacro- 
iliac synchondroses. 

The  Contiguous  Anatomy. 

The  Relations  of  the  Common  Iliac  Arteries.    (Gray.) 


In  front. 

In  front. 

Small  intestines. 

Peritonfeum. 

Peritonaeum. 

Small  intestines. 

Sympathetic  nerves. 

Sympathetic  nerves. 

Rectum 

L. 

Ureter. 

Superior  hsemorrhoidal  artery. 

Ureter. 

Outer  side. 

Inner 

'  side. 

Outer  side. 

'   Right    -^   Vena  cava. 

Left  common 

Left     "1       Psoas  muscle, 
common 

comuiou      Right  common 

iliac 

vein. 

iliac      [       iliac  vein. 

iliac 

.  artery.  J    Psoas  muscle. 

.  artery.  . 

Behind. 

Behind. 

Right  and  left  common 

Left  common 

iliac  veins. 

iliac  vein. 

Last  two  lumbar  vertebrae. 

Last  two  lumbar  vertebrae. 

The  Linear  Guide  to  the  Vessels. — An  imaginary  line  crossing  the  ab- 
domen, between  the  highest  portions  of  the  iliac  crests,  corresponds  very 
nearly  indeed  to  the  level  of  origin  of  the  iliac  arteries.  The  vessels  run 
divergently  from  a  point  in  this  line  a  little  to  the  left  of  the  center  of 
the  abdomen  downward  and  outward  on  either  side  to  a  little  within  a  mid- 
point between  the  pubes  and  the  anterior  superior  spinous  process. 

There  are  two  general  methods  of  access  to  the  common  iliac  artery :  one, 
by  entering  the  abdominal  cavity  from  in  front  (transperitoneal),  the  other 
by  raising  the  peritonaeum  through  an  incision  made  down  to  it  at  the  side  of 
the  abdomen  (extraperitoneal).     Trendelenburg  pose  best  in  both  methods. 

The  First  Method  (Transperitoneal) . — At  present  this  method  is  gener- 
ally accepted  as  a  substitute  for  the  latter  one,  especially  in  those  cases  in 
which  the  latter  is  of  doubtful  expediency.  The  outer  border  of  the  rectus 
abdominis  muscle,  or  more  properly  the  linea  semilunaris,  is  the  best  super- 
ficial guide  to  the  vessel  in  this  method.  The  linese  semilunares  extend  down- 
ward on  either  side  of  the  abdomen  from  the  cartilage  of  the  ninth  rib  to  the 
spine  of  the  pubes,  arching  slightly  outward.  In  the  abdomen  of  a  normal 
adult  these  lines  are  about  three  inches  transversely  from  the  umbilicus. 
The  relations  of  the  common  iliac  arteries  and  veins  are  intricate,  and  are 
dissimilar  on  the  respective  sides  (Fig.  179),  and  therefore  they  should  be 
thoroughly  understood  before  beginning  the  operation. 

The  Operation. — An  incision  five  inches  in  length,  and  three  inches  to 
the  left  of  the  median  line  (Fig.  181,  c), is  made  carefully  into  the  abdominal 
cavity ;  the  omentum  is  raised  upward,  the  intestines  are  pushed  aside,  the 
vessel  is  located  with  the  fingers,  and  a  small  opening  is  made  through  the 
peritonaeum  covering  the  vessel,  and  the  vessel  ligatured  bypassing  the  needle 
around  it  from  without  inward  on  the  right  and  from  within  outward  on 


THE  LIGATURE  OF  ARTERIES. 


133 


the  left  side.     That  is  to  say,  the  needle  is  passed  from  the  vein  nearest 
the  vessel  in  each  instance  (Fig.  183).    The  external  wound  is  then  closed. 

An  incision  through  the  rectus  corresponding  to  the  iliac  artery  to  be 
tied  should  be  employed  in  lieu  of  the  former  incision,  and  the  vessel 
exposed  in  the  same  careful  manner  (Fig.  181,  a). 

The  Results.— Of  19  cases,  14  died  and  5  recovered.  Five  were  tied  for 
hemorrhage,  4  died  and  1  recovered.  Thirteen  for  cure  of  aneurism,  9 
died  and  4  recovered.  One  for  malignant  disease,  result  fatal.  Ten  were 
done  before  1883,  all  died.  Since  1883  these  vessels  have  been  ligatured 
aseptically  nine  times,  4  died  and  5  recovered. 

The  Second  Method  {Extraperitoneal) . — In  this  method  the  abdominal 
cavity  is  unopened. 

There  are  Two  Linear  Guides  to  this  Method. — In  one  (Crampton) 
is  a  line  drawn  from  the  apex  of  the  cartilage  of  the  last  rib  downward 
and  a  little  forward  nearly  to  the  crest  of  the  ilium,  then  carried  forward 
parallel  with  it  to  a  little  below  ^ 

the  anterior  superior  spine    (Fig. 
180,  h,  and  Fig.  182). 

In  the  other  (McKee)  a  line 
drawn  downward  from  the  tip  of 
the  cartilage  of  the  eleventh  rib  to 
a  point  an  inch  and  a  half  within 
the  anterior  superior  spine,  then 
curved  downward,  forward,  and 
inward,  and  terminating  abruptly 
above  the  internal  abdominal  ring 
(Fig.  180,  c). 

The  Muscular  Guide.  —  There 
is  no  stqjerficial  muscular  guide  to 
the  common  iliac  artery  except  the 
rectus  abdominis,  and  then  only  in 
the  median  operation.  The  inner 
border  of  the  psoas  magnus  is,  how- 
ever, an  undeviating  and  markedly 
prominent  deep  muscular  guide. 

The  Operation. — Place  the  pa- 
tient on  the  back  (in  the  Trendelen- 
berg  posture  if  desirable),  the  body 

inclined  to  the  opposite  side,  and  with  the  thighs  slightly  flexed  to  relax 
the  abdominal  walls.  The  various  layers  of  tissue  composing  the  abdominal 
wall  are  divided  down  to  the  fascia  transversalis,  which  is  cautiously  raised 
with  forceps  at  the  upper  end  of  the  wound,  where  it  is  less  dense  and  less 
firmly  attached ;  a  small  opening  is  made  through  it ;  the  finger  is  then 
passed  beneath  it,  and  the  fascia  is  divided  to  the  full  extent  of  the  wound. 
An  assistant  standing  on  the  opposite  side  of  the  body  then  introduces  his 
hand  into  the  wound  and  raises  the  peritona3um  gently  upward  and  inward, 
while  the  operator,  by  the  aid  of  the  finger  or  handle  of  the  scalpel,  sepa- 
11 


d  f 

Fig.  182. — Incision   for    ligaturing  common 

iliac  artery.     (Crampton.) 
a.  Peritona3um.     b.  Ureter,     c.  Common  iliac 

artery,     d.  Common  iliac  vein.    /.  Psoas 

muscle. 


134 


OPERATIVE  SURGERY. 


rates  it  carefully  from  the  tissues  beneath.  When  the  psoas  magnus  is 
reached,  the  surgeon  should  appreciate  the  relations  of  the  dissection  to 
the  exact  location  of  the  artery.  If  the  external  iliac  artery  be  felt  first, 
it  is  to  be  followed  upward  to  the  common  iliac ;  when  the  common  iliac  is 
reached,  the  areolar  tissue  surrounding  it  is  scratched  aside  by  the  director, 
and  the  needle  armed  with  the  ligature  is  passed  as  already  indicated — 
the  needle  with  the  adjustable  end  being  preferable  for  this  operation  (Fig. 
183). 

The  Dangers. — The  dangers  attending  this  operation  are  of  considerable 
magnitude.     The  peritonaeum  may  be  lacerated,  the  ureter  included  in  the 

ligature,  or  the  veins 
punctured  by  the  needle. 
The  assistant  who  raises 
the  peritonaeum  should 
keep  the  fingers  closely 
approximated,  using  both 
hands,  if  necessary,  and 
being  careful  that  the 
fingers  do  not  become  too 
much  flexed,  else  they 
may  lacerate  it.  If  the 
patient  struggle,  vomit, 
or  cough,  the  perito- 
ngeum  should  be  per- 
mitted to  return  to  its 
normal  site  until  quiet  is 
restored.  The  traction 
necessary  to  separate  and 
elevate  the  peritonaeum 
can  not  be  made  too  carefully,  and  it  is  better  if  it  be  done  during  the  acts 
of  expiration,  since  at  this  time  the  downward  pressure  of  the  abdominal 
contents  takes  place.  Large,  broad  retractors  are  sometimes  employed  for 
this  purpose,  but  they  are  much  less  reliable  than  the  hands  of  an  intelligent 
assistant. 

The  ureter  crosses  the  artery  at  the  point  of  bifurcation  of  the  vessel,  and 
it  is  in  little  danger,  since  it  is  usually  raised  along  with  the  peritoneeum 
and  the  subjacent  tissue.  The  veins  can  be  avoided  by  remembering  to  pass 
the  needle  away  from  them.  This  will  be  somewhat  difficult  on  the  right 
side,  owing  to  the  large  venous  trunks  in  close  contact  with  either  side  of 
the  artery.  If  the  vein  obscures  the  arterial  trunk,  pressure  upon  it  below 
the  point  to  be  ligatured  will  diminish  its  size  by  obstructing  the  venous 
return,  and  thus  permit  the  easy  exposure  of  the  artery. 

The  Fallacies. — The  external  iliac  artery  may  be  mistaken  for  the  com- 
mon iliac  artery.  The  fact  that  the  sacro-vertebral  prominence  is  above  the 
external  iliac  artery  should  settle  the  doubt  as  between  the  two.  The  liga- 
ture may  be  applied  too  near  the  bifurcation,  owing  to  the  difficulty  of  find- 
ing it  on  account  of  obscure  light  and  the  intimate  relation  of  the  vessels 


Fig.  183. — Ligature  of  common  iliac  artery. 


THE  LIGATURE  OF  ARTERIES.  135 

with  each  other.  Careful  scrutiny  only  will  prevent  this  mistake  from 
occurring.  The  author  once  mistook  temporarily  the  left  for  the  right  com- 
mon iliac  artery  owing  to  an  abnormality  of  the  bifurcation  of  the  aorta. 
However,  pressure  made  on  the  vessel  before  tying  rectified  the  error. 

The  Results. — Of  59  cases  reported,  18  died  and  41  recovered.  Thirty- 
four  of  which  were  done  for  aneurism,  of  these,  13  lived  and  21  died;  18 
were  done  for  haemorrhage,  4  lived  and  14  died;  7  were  done  for  malignant 
disease,  1  lived  and  6  died.  Of  the  59  cases,  53  were  done  before  1883,  of 
these,  35  died  and  18  recovered.  Six  were  done  aseptically  since  1883,  all 
died. 

Ligature  of  the  Internal  Iliac  Artery. — The  internal  iliac  is  ligatured  to 
control  the  circulation  of  a  pelvic  viscus  and  to  arrest  of  haemorrhage. 

The  Anatomical  Points. — The  internal  iliac  artery  is  about  an  inch  and 
a  half  in  length,  and  extends  from  the  bifurcation  of  the  common  iliac 
downward  and  forward  to  near  the  upper  border  of  the  great  sacro-sciatic 
foramen. 

The  Contiguous  Anatomy. 

Relations  of  the  Internal  Iliac  Artery.    (Gray.) 
I7i  front. 
Peritonaaum. 
Fascia. 
Ureter. 

Outer  side.  I  Internal  )  Inner  side. 

Psoas  magnus.  -j      iliac      >•  Internal  iliac  vein. 

(    artery.    )  Peritoneum. 

Behind. 
External  iliac  vein  (above). 
Interna]  iliac  vein. 
Lumbo-sacral  nerve. 
Pyriformis  muscle. 
Sacrum. 

The  internal  iliac  artery  possesses  no  practical  linear  or  muscular 
guide  other  than  its  relation  to  the  inner  border  of  the  psoas  magnus 
muscle. 

The  Primary  Incisions. — Either  of  the  incisions  employed  in  the  liga- 
ture of  the  common  iliac  (Figs.  180  and  181)  ;  or  an  incision  five  inches  in 
length,  parallel  with  the  epigastric  artery;  or  a  curved  incision  through  the 
linear  semilunaris  (transperitoneal)  about  seven  inches  in  length,  made 
three  inches  to  the  outer  side  of  the  umbilicus,  with  its  convexity  outward, 
and  ending  just  to  the  outer  side  of  the  external  abdominal  ring,  can  be 
employed.  The  intestines  are  carried  upward,  aided  by  the  Trendelenburg 
posture,  the  brim  of  the  pelvis  is  sought,  the  artery  located  as  it  extends 
into  the  pelvic  cavity,  peritonseum  scratched  through,  carefully  avoiding 
the  ureter,  and  the  needle  is  passed  cautiously  away  from  the  vein.  The 
vessel  is  tied  through  an  incision  made  into  tne  abdominal  cavity  in  the 
median  line  below  the  umbilicus. 


136 


OPERATIVE  SURGERY. 


The  Operation  {Extraperitoneal) . — The  tissues  are  divided  successively 
in  the  line  of  the  primary  incision,  the  peritonaeum  is  elevated  in  a  cautious 
manner,  the  ligature  is  carried  around  the  vessel  from  within  outward,  care- 
fully avoiding  the  ureter,  and  also  the  external  iliac  vein. 
The  internal  iliac  artery  may  be  mistaken  for  the  external. 
The  Results. — Of  31  cases  of  ligature  by  the  extraperitoneal  route,  22 
died;  of  29  for  aneurism,  20  died;  of  2  for  haemorrhage,  both  died;  of  30 
done  before  asepsis,  22  died;  one  with  asepsis  recovered.  Meyer  simul- 
taneously thus  tied  both  arteries  under  asepsis  in  5  cases  for  prostatic 
hypertrophy,  all  recovered.  Transperitoneal  aseptic  ligature  gives  the  best 
result :  of  9  cases,  2  died ;  of  5  done  for  aneurism,  1  died ;  1  for  haemor- 
rhage, 1  for  tumor,  both  recovered;  of  2  for  prostatic  disease,  1  died. 
Pryor  simultaneously  tied  both  vessels  through  a  median  abdominal  inci- 
sion for  malignant  disease  of  the  uterus  in  34  cases,  with  1  death. 

Ligature  of  the  Gluteal  Artery. — The  gluteal  artery  may  be  injured  by 
direct  violence  and  require  ligaturing  to  arrest  the  hgemorrhage. 

The  Anatomical  Points. — The  gluteal  artery  passes  out  of  the  pelvis  at 
the  upper  border  of  the  great  ischiatic  notch,  above  the  pyriformis  muscle. 

It  is  accompanied  by  venge  comites, 
and  is  covered  by  the  gluteus  maxi- 
mus  muscle. 

The  linear  guide  to  the  vessel,  A, 
B,  is  a  line  extending  from  the  pos- 
terior superior  spinous  process  of  the 
ilium,  to  the  trochanter  major,  with 
the  thigh  rotated  inward.  The  artery 
lies  beneath  the  junction  of  the  upper 
and  middle  thirds  of  this  line  (Fig. 
184). 

The  vessel  lies  at  the  upper  border 
of  the  ischiatic  notch,  which  is  a  deep 
bony  guide  to  it. 

The  Operation.' — Place  the  patient 
on  the  abdomen,  with  the  thighs  ex- 
tended and  rotated  inward  ;  make  an  incision  five  inches  in  length  in  the 
course  of  the  line  already  indicated.  The  direction  of  the  incision  will  corre- 
spond to  the  course  of  the  fibers  of  the  gluteus  maximus  muscle,  which 
fibers  can  be  readily  separated  with  the  handle  of  the  scalpel  and  drawn 
apart  and  the  notch  sought  for.  The  artery  is  then  liberated  from  the  ac- 
companying veins,  and  the  ligature  is  passed  in  the  most  convenient  manner 
(Pig.  185). 

The  Fallacies. — The  artery  may  be   mistaken  for  either  of  the  venae 
comites  ;  otherwise  no  fallacy  need  occur. 

The   Results. — The   operation   itself   implies  but   little   danger   to   the 
patients. 

Ligature  of  the  Sciatic  Artery. — The  sciatic  artery,  like  the  gluteal,  may 
suffer  from  external  violence. 


Pig.  184. — Linear  guides  to  gluteal  (A,  B) 
and  sciatic  arteries  (A,  C,  and  D). 


THE  LIGATURE  OP  ARTERIES. 


137 


The  Anatomical  Points.— The  sciatic  artery  escapes  from  the  pelvis  be- 
low the  pyriformis  muscle,  and  passes  downward  in  the  interval  between  the 
tuberosity  of  the  ischium  and  the  trochanter  major. 

The  Contiguous  Anatoiny.  —  The  vessel  is  covered  by  the  gluteus 
maximus ;  the  sciatic  nerve  accompanies  it,  and  it  is  posterior  to  the  pudic 
artery. 

The  linear  guides  to  the  vessel  are  two  in  number,  one  (Fig.  184)  of 
which  {D)  is  drawn  parallel  with  the  linear  guide  to  the  gluteal  artery,  only 


GLUTEUS  MAXIMUS    M. 
INF.  GLUTEAL    N  . 
SCIATIC   A. 

'      INT    PUDIC  A. AND  N. 


GLUTEUS  MAXIMUS  M. 
UTEALA. 
SUPERIOR  GLUTEAL  N. 


r]        GLUICVS  MEDIUS  M 
PYRIFORMIS    M. 


Fig.  185. — Ligature  of  sciatic  artery. 


Ligature  of  gluteal  artery. 


about  an  inch  and  a  half  lower  down.  The  second,  A^  C,  extends  from  just 
below  the  posterior  superior  spinous  process  of  the  ilium  to  the  outer  side  of 
the  tuberosity  of  the  ischium. 

The  deep  muscular  guide  is  the  lower  border  of  the  pyriformis,  beneath 
which  the  artery  passes  from  the  pelvis. 

The  Operation. — An  incision  is  made  three  or  four  inches  in  length  ob- 
liquely across  the  linear  guide  in  the  course  of  the  fibers  of  the  gluteus  maxi- 
mus ;  the  fibers  of  this  muscle  are  separated  and  drawn  apart,  the  nerves  and 
veins  are  pushed  aside,  and  the  ligature  is  carried  around  the  vessel,  care 
being;  taken  to  avoid  the  vein  which  lies  to  its  outer  side. 

The  Fallacies.-— The  sciatic  artery  may  be  mistaken  for  the  pudic  artery, 
which  lies  internal  to  it;  however,  the  direction  taken  by  the  respective 
vessels  should  make  the  distinction  between  them  easy. 

The  Results. — The  prognosis  as  to  life  is  always  good  so  far  as  the  oper- 
ation itself  is  concerned. 

Ligature  of  the  Internal  Pudic  Artery. —  The  internal  pudic  artery 
can  be  ligatured  or  compressed  in  the  periuffium  to  control  bleeding  at 
the  penis. 


138 


OPERATIVE  SURGERY. 


Fig.  186. — Passing  needle  around 
pudic  artery. 


The  Anatomical  Points. — The  internal  pudic  artery  escapes  from  the 
pelvis  through  the  greater  sacro-sciatic  foramen  below  the  pyriformis  mus- 
cle, lying  internal  to  the  sciatic  artery ;  it  then  enters  the  pelvis  through 
the  lesser  sacro-sciatic  foramen,  and  runs  along  the  inner  surface  of  the 
ramus  of  the  ischium  and  pubes,  till  it  divides  into  terminal  branches. 

The  Contiguous  Anato7ny. — The  vessel  runs 
along  the  outer  boundary  of  the  ischio-rectal 
fossa,  resting  upon  the  obturator  internus  mus- 
cle, in  a  canal  formed  by  the  obturator  fascia, 
and  accompanied  by  the  pudic  veins  and  the 
internal  pudic  nerve. 

The  linear  guide  to  the  operation  in  the 
peringeum  extends  from  the  arch  of  the  pubes 
to  the  inner  border  of  the  tuber  ischii. 
The  artery  is  situated  about  an  inch  and  a 
quarter  above  the  lower  margin  of  the  tuber 
ischii. 

This  vessel  may  be  ligatured  in  two  situa- 
tions :  1.  At  the  greater  sacro-sciatic  foramen 
(Fig.  185).  2.  In  the  peringeum  (Fig.  186). 
At  the  first  situation,  the  incision  for  ligaturing 
the  sciatic  artery  is  sufficient  for  ligaturing 
this  one,  the  pudic  being  found  internal  to  that  artery,  and  lower  down, 
accompanied  by  its  veins  and  the  pudic  nerve. 

The  Operation  (peringeum). — The  patient  is  placed  in  the  lithotomy 
position,  and  an  incision  is  made  about  four  inches  in  length  in  the  course 
of  the  line  indicated ;  the  tissues  are  carefully  divided  down  to  the  vessel, 
which  is  then  isolated  from  the  veins  and  nerves  and  needle  passed  from  the 
vein  and  vessel  tied  (Fig.  187).  If  care  be  not 
taken  the  crus  penis  will  be  cut.  The  introduction 
of  a  sound  into  the  urethra  will  define  its  outlines, 
and  the  danger  of  wounding  it  will  be  obviated. 

Ligature  of  the  Dorsalis  Penis  Artery.— The 
dorsal  artery  of  the  penis  may  be  tied  on  the  dor- 
sum of  the  organ  by  making  an  incision  an  inch  in 
length  at  either  side  of  the  dorsum,  and  on  a  line 
parallel  to  the  center  of  its  long  axis.  The  artery 
is  superficial,  and  is  attended  by  veins  and  nerves, 
which  should  be  carefully  avoided  in  passing  the 
needle. 

Ligature  of  the  External  Iliac  Artery. — The  external  iliac  artery  is  an 
important  vessel,  surgically,  and  is  frequently  ligatured. 

The  Anatomical  Points. — The  external  iliac  artery  is  about  four  inches 
long,  and  passes  obliquely  downward  and  outward  to  Poupart's  ligament, 
nearly  corresponding  to  a  line  drawn  from  the  left  side  of  the  umbilicus 
to  midway  between  the  anterior  superior  spinous  process  of  the  ilium  and 
the  symphysis  pubis. 


\t-pudic  nerve 


Fig.  187. — Relations  of  the 
pudic  artery. 


THE  LIGATURE   OP  ARTERIES. 


139 


Tlie  Contiguous  Anatomy. 

The  Relations  of  the  External  Iliac  Artery.     (Gray.) 
In  front. 
Peritonseum,  intestines,  and  iliac  fascia. 
Spermatic  vessels. 

Genital  branch  of  genito-crural  nerve. 
Circumflex  iliac  vein. 
Lymphatic  vessels  and  glands. 

Inner  side. 


Near 
Poupart's 
Ligament. 


Outer  side. 
Psoas  magnus. 
Iliac  fascia. 


External  iliac  vein  and  vas 
deferens  at  femoral  arch. 


i  External 
■j      iliac 
'    artery. 

Behind. 
External  iliac  vein. 
Psoas  magnus. 
Iliac  fascia. 

It  has  no  superficial  muscular  or  bony  guides.  The  psoas  magnus,  at  the 
inner  border  of  which  it  lies,  is  a  most  important  deep  muscular  guide.  It 
is  ligatured  at  about  the  middle  of  its  course. 

The  Operation. — A  strong  light  should  be  at  hand  in  this  operation. 
Before  beginning,  evacuate  the  contents  of  the  bladder  and  rectum  of  the 
patient.  Place  him  in  a  recumbent  position,  with  the  thigh  slightly  flexed 
and  the  body  inclined  to  the  opposite  side  or  in  Trendelenburg's  posture. 
A  curvilinear  incision  is  then  made,  with  the  convexity  downward,  be- 
ginning about  an  inch  above  Poupart's  ligament  and  immediately  to  the 
outer  side  of  the  external  abdominal  ring,  and  terminating  on  a  level  with, 
but  about  two  inches  internal  to,  the  anterior  superior  spinous  process 
of  the  ilium  (Fig.  181,  /).  The  superficial  fascia,  aponeurosis  of  the  ex- 
ternal oblique,  the  muscular  fibers  of  the  internal  oblique  and  the  trans- 
versalis,  are  separately  di- 
vided upon  a  grooved  di- 
rector. The  fascia  trans- 
versalis  is  carefully  picked 
up  with  the  thumb  for- 
ceps and  a  small  opening 
made  through  it,  into 
which  the  director  is  in- 
serted and  the  fascia  di- 
vided. The  peritonaeum 
and  its  subserous  tissue 
are  then  carefully  raised 
from  the  iliac  fascia,  and 
pressed  upward  and  in- 
ward until  the  outer  bor- 
der of  the  psoas  magnus  is  ascertained,  when,  after  a  little  further  separa- 
tion, the  vessel  is  felt  pulsating  at  the  inner  margin  of  this  muscle. 

The  condensed  areolar  tissue  constituting  its  sheath  is  then  opened,  and 
the  needle  carefully  inserted  between  the  vein  and  artery,  from  within  out- 


GENITO-CRURAL  N. 
DEEP  CIRCUMFLEX  ARTERY. 


INTERNAL    OBLIQUE 
AND  rnmSVERSALIS 
FIBERS 


ILIAC  AHTERY. 

ILIAC  VEIN. 


DEEP  EPIGASTRIC 
ARTERY. 

(APONEUROSIS 
lOF  E/TERNAL. 
[OBUQUC  MUSCLE. 


PSO ASM AGNUS 

MUSCLE 


Fig.  188. — Ligature  of  external  iliac  artery. 


140  OPERATIVE  SURGERY. 

ward  (Fig.  188).  //  the  incision  he  made  about  a  third  of  an  inch  above 
Poupart's  ligament  (Fig.  181,  d),  the  overlying  fascia  will  be  exposed  with- 
out the  appearance  of  the  peritonseum,  since  the  latter  is  reflected  upward 
and  backward  into  the  pelvis  at  a  little  distance  above  this  point.  By  this 
plan  the  vessel  can  be  ligatured  with  a  minimum  amount  of  danger  from 
disturbance  of  the  deep  tissues.  The  incisions  for  securing  the  deep  epi- 
gastric and  deep  circumflex  iliac  arteries  near  to  their  origin  can  be  utilized 
(Fig.  180,  d)  for  tying  these  vessels  and  the  iliac  also  when  needful. 

The  transperitoneal  method  can  be  practiced  in  this  instance  through  a 
vertical  incision,  or  through  the  "gridiron"  route  for  appendicitis  (Vol. 
II)  if  desirable.  We  are  disposed  to  regard  the  method  favorably  when 
employed  for  special  reasons  and  with  a  knowledge  of  thorough  asepsis. 

The  Fallacies. — The  external  oblique  aponeurosis  may  be  mistaken  for 
the  deep  layer  of  superficial  fascia.  The  muscular  fibers  of  the  internal 
oblique  will  then  be  mistaken  for  those  of  the  external  oblique.  If,  how- 
ever, the  direction  of  the  fibers  of  the  respective  muscles  be  recalled,  and, 
furthermore,  that  the  external  oblique  has  no  muscular  fibers  in  this  situ- 
ation, the  mistake  will  be  quickly  rectified.  The  fascia  transversalis  may 
be  mistaken  for  the  peritonaeum ;  this  fallacy  is  easily  detected  by  follow- 
ing it  downward,  when,  if  it  be  attached  to  Poupart's  ligament,  or  passes  be- 
neath it,  it  can  not  be  the  peritonaeum,  and  must  be  the  transversalis  fascia. 
If  its  relations  to  the  previously  divided  tissues  be  taken  into  account,  to- 
gether with  its  density  and  opacity,  this  mistake  can  hardly  occur. 

The  iliac  fascia  may  be  mistaken  for  the  subserous  tissue,  and  be  raised 
together  with  the  peritonaeum.  Under  such  circumstances  the  vessel  will  be 
raised  upward  together  with  the  peritonaeum  and  iliac  fascia,  and  will  be  felt 
pulsating  in  the  roof  rather  than  the  floor  of  the  operation- wound.  This  mis- 
take can  be  avoided  by  remembering  that  the  iliac  and  psoas  muscles  are  cov- 
ered by  a  dense  fascia,  which  passes  out  of  the  pelvis  beneath  Poupart's  ligament, 
to  which  it  is  attached,  and  that  the  artery  does  not  lie  beneath  but  upon  it. 

If  an  irreducible  inguinal  hernia  exist,  or  the  vein  be  adherent  to  the 
artery,  then  much  difficulty  may  be  experienced  in  properly  placing  the 
ligature  without  injury  to  the  intestines  or  the  vein.  After  ligaturing, 
the  wound  must  be  thoroughly  closed  by  carrying  the  sutures  deeply,  near 
to  the  peritongeum,  the  superficial  tissues  (integument  and  fascia)  being 
united  separately.  If  this  be  not  done,  the  patient  will  be  exposed  to  the 
danger  of  the  occurrence  of  a  hernial  protrusion,  due  to  the  weakening  of 
the  abdominal  walls.  This  is  a  precaution  which  should  always  be  taken 
in  operations  involving  the  separation  of  the  peritonaeum. 

The  Results. — Of  164  cases,  139  recovered  and  33  died;  of  118  done 
before  antisepsis,  93  recovered,  25  died;  of  44  under  asepsis,  36  recovered, 
8  died.  Of  the  118,  81  were  for  aneurism,  74  recovered,  7  died;  35  for 
haemorrhage,  20  recovered,  15  died;  of  2  for  tumor,  both  died.  One  of  the 
118  was  done  transperito-neally  and  recovered;  34  were  for  aneurism,  29 
recovered,  5  died;  9  for  haemorrhage,  6  recovered,  3  died;  one  for  tumor 
recovered.  Of  25  done  extraperitoneally,  20  recovered  and  5  died;  of  19 
done  transperitoneally,  16  recovered  and  3  died. 


THE  LIGATURE  OF  ARTERIES. 


141 


liiBifflSjDif 


INTERNAL  OBLiqUE 


PECTUS  ABDOMINIS 


APONEUROSIS    OF 
EXTERNAL  OBLIQUE 


VEN/E  C0MITE5. 


I  THIN    FASCIA 
\tRAN5VERSAUS. 


PERITONEUM. 


DEEP 
[EPIGASTRIC  A 


]-€' 


I 


TENSOR  VAGIN.  FEM.  M. ,    ,^5*0 


yf 


'EXT.CUTANE0U5  N 


Ligature  of  Deep  Epigastric  Artery. — This  artery  arises  from  the  lower 
portion  of  the  external  iliac  (Fig.  189)  and  runs  upward  toward  the 
umbilicus,  between  the  peritongeum  and  the  transversalis.  It  lies  at  the 
inner  border  of  the  internal  abdominal  ring  (see  Hernia,  Vol.  II). 

The  Linear  Guide. — A  line  extending  from  the  umbilicus  to  the  mid- 
dle of  Poupart's  ligament  corresponds  to  the  course  of  the  vessel.  The 
vessel  may  be 
tied  after  suc- 
cessive division 
of  overlying  tis- 
sues near  to 
the  origin,  as 
demonstrated  by 
Fig.  188,  as  well 
as  three  or  four 
fingers'  breadths 
higher  than  this 
(Fig.  189). 

The  Opera- 
tion.— An  inci- 
sion is  made 
about     three 

.       -  ,  APONEUROSIS  OF  internal      rf 

inches  m  length,  oblique  and  transversals  / 
at  either  of  the 
foregoing  situ- 
ations, parallel 
with  Poupart's 
ligament.  The 
various  layers  of 
the  abdominal 
wall  are  then 
divided  sepa- 
rately upon  a 
grooved  direc- 
tor until  the 
fascia  transver- 
salis is  reached, 
which  is  opened 
over  the  artery, 
the  connective 
tissue  and  the 
veins  separated 
from  it,  and  the 

ligature  properly  placed  (Fig.  189).  The  wound  should  then  be  carefully 
closed,  and  the  patient  kept  quiet  in  a  recumbent  posture  until  the  tissues 
are  firmly  united,  else  a  weak  point  in  the  abdominal  walls  may  follow  at 
the  seat  of  operation. 


fascia  LffTA. 

FASCIA  OVER  OBTURATOR  EXT.  M. 

ORTURATOR  EXT.  M. 

OBTURATOR    A. 

OBTURATOR    N. 

FEMORAL    V. 

INT.  SAPHENOUS    V. 

FEMORAL  A . 

PECTIN  EUS     M. 

PECTINEAL    FASCIA. 


Fig.  189. — Epigastric  and  obturator  arteries, 
obturator  and  external  cutaneous  nerves. 


142  OPERATIVE  SURGERY. 

Ligature  of  the  Deep  Circumflex  Iliac  Artery. — The  deep  circumflex  iliac 
artery  can  be  secured  at  two  situations:  1,  at  the  internal  abdominal  ring; 
3,  near  the  anterior  superior  spinous  process  of  the  ilium.  In  the  first  situa- 
tion it  may  be  tied  at  the  same  incision  as  that  for  the  epigastric  artery  ( Fig. 
180,  d).  In  the  second  it  may  be  secured  through  an  incision  made  parallel 
to  and  just  above  Poupart's  ligament,  at  the  outer  side  of  the  course  of  the  epi- 
gastric artery  (Fig.  181,  e),  through  the  various  tissues  anterior  to  the  trans- 
versalis  fascia,  which  is  then  opened,  the  artery  isolated  (Fig.  188)  and  tied. 

Ligature  of  the  Femoral  Artery. — The  femoral  artery  is  of  special  surgical 
significance  on  account  of  its  exposed  situation  and  the  frequent  presence  of 
morbid  growths  in  the  thigh. 

The  Anatomical  Points. — The  femoral  artery  extends  from  Poupart's 
ligament  to  the  lower  extremity  of  Hunter's  canal,  at  the  junction  of  the 
middle  and  lower  thirds  of  the  tliigh,  where  it  terminates  in  the  popliteal. 
About  two  inches  below  Poupart's  ligament  it  gives  ofE  the  profunda  femoris 
or  deep  femoral  artery. 

The  Contiguous  Anatomy. 

The  Relations  of  the  Common  Femoral  Artery.     (Gray.) 
In  front. 
Skin  and  superficial  fascia. 
Superficial  inguinal  glands. 
Iliac  portion  of  fascia  lata. 
Prolongation  of  transversalis  fascia. 
Crural  branch  of  genito-erural  nerve. 
Superficial  circumflex  iliac  vein. 
Superficial  epigastric  vein. 
Inner  side.  Outer  side. 

Femoral  vein.  (  Common  ^  Anterior  crural  nerve. 

femoral  r 
artery.    ; 

Behind. 
Prolongation  of  fascia  covering  iliacus  muscle. 
Pubic  portion  of  fascia  lata. 
Nerve  to  pectineus. 
Psoas  muscle. 
Pectineus  muscle. 
Capsule  of  hip  joint. 

The  Relations  of  the  Superficial  Femoral  Artery.     (Gray.) 
In  front. 
Skin,  superficial  and  deep  fasciae. 
Internal  cutaneous  nerve. 
Sartorius  muscle. 

Aponeurotic  covering  of  Hunter's  canal. 
Internal  saphenous  nerve. 
Inner  side.  Outer  side. 

Adductor  longus.  i  Superficial ')  Long  saphenous  nerve. 

Adductor  magiius.  <     fem.oral     [•  Nerve  to  vastus  internus. 

Sartorius.  '      artery,      j  Vastus  internus. 

Femoral  vein  (below). 


THE   LIGATURE   OF   ARTERIES.  143 

Behind. 

Femoral  vein. 
Profunda  artery  and  vein. 
Pectineus  muscle. 
Adductor  longus. 
Adductor  magnus. 

The  linear  guide  to  the  artery,  throughout  its  whole  course,  is  a  dotted 
line  drawn  from  midway  between  the  anterior  superior  spinous  process  of 
the  ilium  and  the  symphysis  pubis  to  the  inner  condyle  of  the  femur  (Fig. 
184). 

A  dotted  line  drawn  from  the  origin  of  the  adductor  longus  to  the  in- 
sertion of  the  adductor  magnus  tendon  into  the  internal  condyle  of  the 
femur  also  corresponds  to  the  femoral  artery  in  Hunter's  canal. 

The  Muscular  Guides. — The  sartorius  is  a  muscular  guide ;  the  artery 
lies  at  the  inner  border  in  the  upper  third,  behind  the  muscle  in  the  middle, 
and  at  the  outer  side  in  the  lower  third.  The  better  muscular  guide  to  the 
lower  third  is  the  inner  border  of  the  tendon  of  the  adductor  magnus.  This 
tendon  can  be  quite  easily  felt,  but  care  must  be  taken,  otherwise  it  will  be 
mistaken  for  one  of  the  ham-string  tendons. 

The  femoral  artery  is  ligatured  at  three  situations :  1,  just  below  Pou- 
part's  ligament ;  2,  at  the  apex  of  Scarpa's  triangle,  or  about  four  inches 
below  the  ligament ;  3,  in  Hunter's  canal.  The  most  favorable  situations 
are  at  the  apex  of  Scarpa's  triangle  and  in  Hunter's  canal.  However,  cir- 
cumstances often  arise  which  necessitate  its  being  tied,  irresj)ective  of  the 
stereotyped  situations. 

The  Ojjeration.  The  First  Situation — Common  Femoral  (Fig.  190,  a). — 
The  vessel  can  be  ligated  immediately  below  Poupart's  ligament  through 
either  of  two  incisions :  one  is  made  in  the  long  axis  of  the  vessel  (dotted 
line),  the  other  parallel  with  the  lower  border  of  the  ligament  (Fig.  181,  g). 
The  former  is,  how^ever,  the  better  incision.  The  patient  is  placed  on  the 
back  and  the  thigh  flexed  and  rotated  outward.  The  pulsation  of  the  artery 
is  noted  by  the  finger,  then  an  incision  about  three  inches  in  length  is 
made  through  the  integument  and  subcutaneous  tissues;  the  lymphatic 
glands  drawn  aside,  fascia  lata  divided  on  a  director  in  the  usual  manner, 
and  the  arterial  sheath,  which  is  very  dense,  is  opened,  and  the  needle  passed 
from  within  outward.  The  vein  Avill  be  noticed  at  its  inner  side,  inclosed 
in  a  common  sheath  with  it,  but  sejjarated  from  the  artery  by  a  fibrous 
partition.  The  attention  of  the  surgeon  should  be  directed  to  the  pink- 
ish-white pulsating  vessel  rather  than  to  seeking  for  the  vein  (Fig.  191). 
If  the  attention  and  manipulations  be  directed  toward  the  artery,  the  vein 
will  remain  undisturbed  within  its  compartment.  A  ligature  is  rarely  ap- 
plied at  this  situation  on  account  of  the  increased  danger  of  the  occurrence 
of  gangrene  and  secondary  haemorrhage.  Although  the  latter  can  be  ob- 
viated by  ligature  of  the  branches  of  the  vessels  contiguous  to  the  seat  of 
the  operation,  yet  this  measure  of  security  against  hfemorrhage  increases 
the  liability  of  gangrene.  Therefore,  when  possible,  ligature  of  the  external 
iliac  artery  is  preferable  to  the  ligature  of  the  femoral  at  this  location. 


IM 


OPERATIVE   SUHGERY. 


VASTUS  inte:rnas. 

FEMORAL    VEIN. 

FEMORAL  ARTERY. 

I  LONG  SAPHENOUS 
\  NERVE. 

5ART0RIUS  MUSCLE. 


Fig.  190. — Ligature  of  femoral  artery. 

a.  Ligature  of  common  femoral,     h.  Ligature  of  superficial  femoral  at  apex  of  Scarpa's 
triangle,     c,  d.  Ligature  in  Hunter's  canal. 


THE  LIGATURE   OP   ARTERIES. 


145 


The  Second  Situation — Superficial  Femoral. — At  the  apex  of  Scarpa's 
triangle  (Fig.  190,  &),  or  about  four  inches  below  Poupart's  ligament. 

Anatomical  Points. — The  saphenous  vein  runs  along  the  inner  side  of 
this  region,  and  can  be  located  by  pressing  it  above,  thus  causing  distention 


Fig.  191. — Transverse  section  ai  uppi'T  tliinl  of  right  thigh. 
A.  Profunda  artery  and  vein.     B.  Long  saphenous  nerve.     C.  Common  femoral  artery 
and  vein.    D.  Internal  saphenous  vein.     U.  Semimembranosis.     F,  H.  Gluteal  ves- 
sels.    G.  Sciatic  nerve. 


below.  The  femoral  vein  lies  to  the  inner  side,  somewhat  more  posteriorly 
here  than  above  (Fig.  192).  Branches  of  the  internal  cutaneous  nerve  lie  in 
front,  and  the  long  saphenous  lies  deeper  and  to  the  outer  side  of  the  vessel. 

The  Operation. — Place  the  limb  as  in  the  preceding  operation,  and  make 
an  incision  about  four  inches  in  length  along  the  inner  border  of  the  sar- 
torius  muscle ;  divide  the  tissues  down  to  the  fascia  lata,  draw  the  sartorius 
to  the  outer  side,  and  the  pulsation  of  the  vessel  can  be  felt  and  perhaps 
seen  beneath  the  fascia ;  cautiously  open  the  fascia  lata  and  the  sheath  of 
the  vessel,  and  pass  the  needle  from  within  outward.  The  presence  of  a 
broad  sartorius  muscle  diminishes  the  size  of  the  triangle,  correspondingly 
covers  the  vessel  and  thus  obscures  it,  thereby  adding  to  the  difficulty  of 
the  operation. 

The  Third  Situation — Superficial  Femoral — In  Hunter^s  Canal  (Fig. 
190,  c  and  d). — Hunter's  canal  is  located  at  the  middle  third  of  the  thigh, 
and  at  the  inner  side. 


146 


OPERATIVE  SURGERY. 


The  Operation. — Flex  the  thigh  on  the  pelvis  and  the  leg  on  the  thigh, 
and  rotate  the  thigh  outward;  an  incision  is  then  made  along  the  outer 
border  of  the  tendon  of  the  adductor  magnus,  beginning  at  a  point  a  little 
above  the  junction  of  the  middle  and  lower  thirds  of  the  thigh,  and  extend- 


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Pig.  192. — Transverse  section  at  middle  third  of  right  thigh. 
A.  Femoral  artery.     B.  Long  saphenous  nerve.     C.  Internal  saphenous  veins.     D.  Fem- 
oral vein.     IJ.  Profunda  artery  and  veins.      F.  Sciatic  nerve.      G.  Small  sciatic 
artery  and  veins. 

ing  upward  (Fig.  190,  d)  about  four  inches  throu.gh  the  integument  and 
fascia,  when  the  tendon  will  be  readily  felt.  If  the  sartorius  be  in  the  wa}^, 
it  should  be  drawn  to  the  inner  side.  After  the  intervening  soft  parts  are 
pushed  aside,  the  fibrous  canal  (Hunter's  canal)  in  which  the  artery  is  con- 
tained will  be  exposed.  This  structure  is  formed  at  the  inner  side,  by  the 
tendon  of  the  adductor  magnus,  at  the  outer,  by  the  inner  border  of  the 
vastus  internus  muscle,  and  elsewhere  by  the  fibrous  reflections  extending 
between  the  muscles.  The  canal  is  cautiously  opened,  and  the  long  saphe- 
nous nerve  is  seen  resting  upon  the  vessel;  the  nerve  is  drawn  aside  and 
the  needle  is  passed  from  without  inward,  thus  avoiding  the  femoral  vein, 
which  is  now  located  posteriorly  and  externally  to  the  artery  (Figs.  193, 
and  190,  d).  The  vessel  can  be  ligatured  at  this  situation  by  making  an 
incision  of  a  similar  length  on  the  linear  guide  first  described  (Fig.  190, 
c  c).  It  is  not  so  satisfactorily  secured,  however,  by  this  as  by  the  former 
method. 

The  Fallacies. — The  sartorius  muscle  may  be  mistaken  for  other  muscles 
lying  in  the  general  course.  If,  however,  it  be  recollected  that  no  other 
muscles  run  in  exactly  the  same  direction  on  the  anterior  surface  of  the 


THE   LIGATURE   OP  ARTERIES. 


147 


VASTUS 
IN  TERN  us  y 


thigh  as  the  sartorins,  and  that  it  is  superficial  throughout  the  entire  course, 
no  great  confusion  can  arise.  The  lymphatic  glands  that  lie  over  the  sheath 
of  the  vessel  in  the  upper  portion  of  its  course  may  be  mistaken  for  the 
vessel  itself,  owing  to  their  color  and  to  the  transmitted  pulsation.  The 
glands  are  irregular,  movable,  and  can  be  raised  upward,  when  the  apparent 
pulsation  will  cease ;  moreover,  the  artery  is  beneath  the  fascia  lata,  and  the 
glands  are  above  it. 

The  tendon  of  the  adductor  magnus  may  be  mistaken  for  the  tendon  of 
the  semimembranosus  or  semitendinosns.  This  mistake  will  be  avoided  if 
the  tendons  be  traced  downward ;  the  two  latter  will  pass  behind  the  inter- 
nal condyle,  while  the  former  will  be  inserted  into  it.  Care  must  be  taken 
in  ligaturing  the  artery  at  the  apex  of  Scarpa's  triangle  not  to  make  the 
incision  too  low  down. 

The  width  of  the  hand  ^^  '  "^"^^^^^^^^^-^ 

below  Poupart's  liga- 
ment is  a  good  practi- 
cal guide  to  the  apex. 
In  ligaturing  the  artery 
in  Hunter's  canal,  it 
should  be  remembered 
that  the  canal  is  located 
at  the  middle  third  of 
the  thigh,  or  otherwise 
the  incision  will  be 
made  too  low  down, 
and  the  upper  portion 
of  the  popliteal  artery 
secured  instead. 

In  a  very  small  num- 
ber of  cases  (four)  the 
femoral  was  double ;  in 
a  like  number  it  passed 
behind  instead  of  in 
front  of  the  thigh.  If 
it  be  double,  the  por- 
tion exposed  will  be 
smaller  than  normal, 
and  the  application  of 
the  ligature  will  not  be 
followed  by  the  anticipated  distal  circulatory  manifestations.  If  the  vessel 
be  not  found  in  its  common  location  it  will  be  necessary  to  seek  for  it  else- 
where, and  deep  pressure  may  enable  one  to  detect  its  anomalous  situation. 
It  may  be  located  behind  the  thigh  or  when  continuous  with  the  internal 
iliac,  escape  from  the  pelvis  through  the  sacro-sciatic  foramen.  The  fem- 
oral vein  may  lie  at  the  inner  side  at  the  apex  of  Scarpa's  triangle  and 
behind  in  Hunter's  canal.  The  author  has  met  with  an  instance  of  this 
kind  in  ligaturing  the  artery  at  the  latter  situation. 


Fig.  193. — Transverse  section  at  lower  third  of  right  thigh. 
A.  Femoral  vein.    B.  Superficial  femoral  artery.     C.  Long 

saphenous   nerve.      JD.   Internal  saphenous   vein.      E. 

Internal  popliteal   nerve.      F.   External  popliteal  or 

perineal  nerve. 


148 


OPERATIVE  SURGERY. 


RECTUS   FEMOR/S 


Fig.  194. — Ligature  of  the  deep  femoral  and  eircuiuflex 
arteries. 


The  Results. — Of  41  ligatures  of  the  common  femoral,  10  died;  of  29 
done  before  asepsis,  9  died;  of  11  for  aneurism,  3  died;  of  17  for  haemor- 
rhage, 5  died;  1  done 
for  tumor,  which  died. 
Of  12  tied  aseptically, 
1  died;  of  the  12,  7 
were  for  aneurism,  1 
died;  5  for  haemor- 
rhage, all  recovered. 
Of  343  ligatures  of 
the  superficial  fem- 
oral, 72  died;  in  309 
cases,  tied  before  asep- 
sis, 68  died;  of  244 
done  for  aneurism,  55 
died;  of  60  for  haem- 
orrhage, 12  died;  of  5 
done  for  tumor,  1 
died.  Of  34  tied  un- 
der asepsis,  4  died;  of  the  34,  24  were  for  aneurism,  and  3  died;  10  for 
haemorrhage,  1  died.  An  older  series  shows  the  following:  The  common 
femoral  has  been  ligatured  31  times  for  aneurism,  with  a  mortality  of  40 
per  cent,  haemorrhage  occurring 
in  60  per  cent  of  the  cases.  The 
superficial  femoral  has  been 
ligatured  204  times,  with  a 
mortality  of  50  cases. 

Ligature  of  the  Deep  Fem- 
oral Artery  (the  Profunda) 
and  the  External  Circumflex. 
— The  relation  which  the  per- 
forating branches  of  this  vessel 
bear  to  the  femur  and  their  lia- 
bility to  injury  in  fracture  is  of 
much  importance.  The  author 
has  seen  a  case  of  death  from 
secondary  hsemorrhage  follow 
rupture  of  the  third  perforating 
branch,  caused  by  fracture  of 
the  femur  (Figs.  194  and  191). 
The  Operation. — The  pro- 
funda and  circumflex  arteries 
are  tied  through  the  vertical  in- 
cision for  ligature  of  the  com- 
mon femoral,  and  sought  for  at 
the  outer  side  of  this  artery.  The  vessel  is  carefully  isolated,  that  the 
ligature  may  be  applied  a  proper  distance  from  the  collateral  branches. 


SEMI-MEM 
BRANOSUS   M 


POPLITEAL  A. 


POPLITEAL    V. 


POPLITEAL    N. 


Pig.  195. — Ligature  of  the  popliteal  artery  at  the 
upper  third. 


THE  LIGATURE  OF  ARTERIES. 


149 


The  Fallacies. — The  profunda  may  arise  from  the  inner  or  back  portions 
of  the  common  femoral.  If  it  be  not  found  in  the  usual  place,  it  should  be 
sought  for  at  the  latter  situations. 

Ligature  of  the  Popliteal  Artery.— The  intimate  association  of  the  poplit- 
eal artery  with  the  posterior  surface  of  the  knee  joint  should  not  be  forgot- 
ten, especially  in  excision.  The  author  knows  of  an  instance  of  the  wound- 
ing of  this  vessel  in  excision  of  this  joint. 

The  Anatomical  Points.— The  popliteal  is  continuous  with  the  femoral 
artery,  and  begins  at  the  junction  of  the  middle  and  lower  thirds  of  the  thigh, 
at  the  termination  of  Hunter's  canal,  and  passes  with  a  slight  obliquity  down- 
ward and  outward  to  the  lower  border  of  the  popliteus  muscle. 

The  Contiguous  Anatomy. 
— At  the  upper  third  of  the 
space  the  internal  popliteal 
nerve  is  more  superficial  than 
the  vein  and  artery.  The  vein 
lies  in  close  contact  with  the 
artery  and  between  it  and  the 
nerve.  The  artery  is  the  inner- 
most of  the  three,  and  is  the 
most  deeply  situated,  resting 
close  to  the  posterior  surface  of 
the  femur.  At  the  lower  third 
the  nerve  is  still  the  most  super- 
ficial, but  lies  upon  and  to  the 
inner  side,  and  more  superficial 
than  the  artery,  which  rests 
upon  the  popliteus  muscle. 
The  artery  should  not  be  tied 
at  its  middle  third,  on  account 
of  the  large  number  of  branches 
given  off  at  this  point,  together 
with  the  fact  of  its  contiguity 
with  the  knee  joint  (Fig.  196). 

The  Linear  Guide. — The  lin- 
ear guide  to  the  vessel  begins  a 
little  to  the  inner  side  of  the  mid- 
dle of  the  upper  portion  of  the 
popliteal  space,  and  passes  midway  between  the  condyles  of  thefemur  (Fig.  195 ) . 

The  Muscular  Guides.— The  artery  at  the  upper  third  lies  to  the  inner 
border  of  the  semimembranosus,  at  its  lower  third,  midway  between  the 
heads  of  the  gastrocnemius  muscle. 

The  artery  can  be  ligatured  at  three  situations— yx^'^ev  and  lower  thirds, 
and  below  the  inner  tuberosity  of  the  tibia.  The  position  of  the  limb  for 
ligaturing,  the  linear  guide,  and  the  anatomy  are  substantially  similar  at  the 
last  situation  as  in  the  upper  part  of  the  posterior  tibial.  Ligaturing  here  is 
rarely  practiced. 


Fig.  196.— Transverse  section  through  the  right 
knee  joint. 
A.  Bursa  patellae.  B.  Internal  saphenous  vein. 
C.  Semimembranosus.  D.  Gracilis.  E.  Semi- 
tendinosus.  F.  Popliteal  artery.  O.  Popliteal 
vein.  H.  External  saphenous  vein.  /.  Inter- 
nal popliteal  nerve.  J.  External  popliteal  or 
perineal  nerve. 


150 


OPERATIVE  SURGERY. 


The  Operation  at  the  Upper  Third  (Fig.  195). — The  patient  can  be 
placed  on  the  face  or  the  baclv;  if  on  the  latter,  the  thigh  should  be  well 
flexed  and  rotated  outward.  The  former  position  is  more  convenient  for  the 
surgeon,  but  is  objectionable  on  account  of  greater  difficulty  in  the  adminis- 
tration of  the  anaesthetic.  The  patient  may  be  placed  on  the  side  corre- 
sponding to  that  of  the  artery  to  be  tied,  with  the  thigh  extended  and  the 
opposite  one  flexed  on  the  pelvis. 

An  incision  is  made,  about  four  inches  in  length,  along  the  outer  border 
of  the  semimembranosus  through  the  integument  and  fascia,  and  is  deep- 
ened by  separating  the  areolar  tissue  with  the  handle  of  the  scalpel.  The 
nerve  will  be  first  seen,  and,  when  drawn  outward,  the  vein  will  be  found 
lying  more  deeply  and  internal  to  it ;  if  the  vein  be  now  carefully  isolated 

and  drawn  outward,  the  artery  will 
be  noted  at  the  inner  side,  and  is 
then  carefully  separated  from  the 
surrounding  tissues  and  the  needle 
carried  around  it  from  without  in- 
ward. 

The  Operation  at  the  Lower 
Third  (Fig.  197). —Make  an  inci- 
sion midway  between  the  heads  of 
the  gastrocnemius,  carefully  avoid- 
ing the  external  saphenous  vein 
and  nerve,  as  they  pass  between 
the  heads  of  that  muscle ;  separate 
the  connective  tissues  with  the 
handle  of  the  scalpel,  draw  the 
vein  and  nerve  to  the  inner  side, 
and  pass  the  needle  from  within 
outward. 

The  Fallacies. — The  tendon  of 
the  semitendinosus  may  be  mis- 
taken for  the  tendon  of  the  semi- 
membranosus muscle.  The  semimembranosus  has  a  large  fleshy  belly,  which 
extends  much  nearer  to  the  median  line  of  the  popliteal  space  than  does  the 
semitendinosus.  Sometimes  there  are  two  popliteal  veins,  one  on  either 
side  of  the  vessel,  and  rarely  two  popliteal  arteries. 

The  Results. — The  popliteal  is  seldom  ligatured  unless  ruptured.  Of  9 
cases  ligatured,  3  died.  Of  5  tied  before  asepsis,  the  2  for  aneurism  recov- 
ered; 3  for  hsemorrhage  died.  Of  four  aseptically,  3  for  haemorrhage,  1 
for  aneurism,  and  1  for  elephantiasis,  all  recovered. 

Ligature  of  the  Anterior  Tibial  Artery. — This  artery  is  often  injured 
in  fracture  of  the  leg. 

The  Anatomical  Points. — It  arises  from  the  popliteal  just  below  the 
popliteus  muscle,  passes  forward  between  the  bones  above  the  interosseous 
membrane  downward  on  the  anterior  surface  of  this  membrane  to  the  ankle 
joint,  becoming  the  dorsalis  pedis  artery. 


Fig.  197. — Ligature  of  popliteal  artery  at  the 
lower  third. 


THE   LIGATURE   OP  ARTERIES. 


151 


The  linear  guide  to  the 
vessel  is  drawu  on  the  an- 
terior surface  of  the  leg 
from  the  inner  border  of 
the  head  of  the  fibula  (*) 
to  midway  between  the 
malleoli  (Fig.  198). 

The  muscular  guide  is 
the  outer  border  of  the 
tibialis  anticus  muscle. 
This  vessel  can  be  tied  at 
three  situations  —  at  its 
upper,  middle,  and  lower 
thirds  ;  but  two — the  mid- 
dle and  lower  thirds — are 
more  than  sufficient  for  all 
practical  purposes. 

The  Operation.  Upper 
Third  (Fig.  19 8,  a)  .—Liga- 
ture at  this  situation  is  te- 
dious and  difficult,  on  ac- 
count of  the  great  depth 
of  the  vessel,  and  should 
not  be  attempted  unless 
circumstances  demand  it. 
Fig.  193  shows  the  deep 
relations  of  the  vessel. 

The  Middle  Third  {'Fig. 
198,  J).— The  artery  in  this 
situation  lies  quite  deeply, 
and  a  good  light  must  be 
had  to  see  the  entire  ex- 
tent of  the  operation- 
wound  (Fig.  200). 

The  Operation. — Place 
the  patient  on  the  back 
with  the  thighs  extended, 
the  leg  turned  inward,  and 
the  foot  forcibly  extended 
to  mark  the  outlines  of 
the  tibialis  anticus  mus- 
cle. Make  an  incision 
four  or  five  inches  in  length 
on  the  line  indicating  the 
course  of  the  artery,  down 
to  the  fascia,  which  is  then 
carefully    divided.       The 


EKTEN.  PROP.   h/\LLUCIS. 
ANT.  TIBIAL   N. 

VEN/E  COMITES, 
■mr. TBI  ALA. 


Fig.  198.— Ligature  of  anterior  tibial  artery. 

a.  At  upper  third.     I.  At  middle  third. 
c.  At  lower  third. 


152 


OPERATIVE  SURGERY. 


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vsV.^^- 


aponeurotic  structure  is  then  severed  along  the  line  of  apposition  between 
the  tibialis  anticus  and  the  extensor  longus  digitorum  muscles ;  it  should 

likewise  be  divided  trans- 
versely inward  to  a  limited 
extent,  to  admit  of  the 
wider  separation  of  these 
muscles.  The  foot  is  then 
flexed,  and,  with  the  finger, 
or  the  handle  of  the  scal- 
pel, the  line  of  separation 
is  extended  directly  down 
to  the  vessel ;  separate  the 
surfaces  of  the  wound  with 
spatulge,  then  the  artery 
with  its  nerve  and  accom- 
panying veins  will  be  seen 
(Fig.  200), the  nerve  being 
in  front  and  on  the  outer 
side ;  separate  the  veins 
from  the  artery,  and  pass 
the  ligature  from  without 
inward. 

The  Operation  at  the 
Lower  Third  (Fig.  198,  c). 
— With  the  limb  as  in  the 
preceding  operation,  ex- 
tend the  foot  to  mark  the 
course  of  the  tendon  of  the 
I  tibialis  anticus ;   make  an 

incision  along  the  external  border  of  the  tendon  on  the  linear  guide  about 
three  inches  in  length.  Divide  the  fascia,  and  seek  with  the  finger  for  the 
space  between  the  tibialis  anticus  and  the  extensor  proprius  pollicis  muscle, 
which  latter  muscle  is  at  the  inner  side  of  the  vessel  below ;  flex  the  foot, 
separate  the  muscles  from  each  other,  and  the  artery  will  be  seen  accom- 
panied by  its  veins  and  nerve,  the  latter  lying  in  front  and  a  little  to  the 
outer  side  (Fig.  201);  isolate  the  artery,  and  place  the  ligature  by  passing 
the  needle  from  without  inward. 

The  Fallacies. — The  outer  surface  of  the  head  of  the  tibia  is  very  liable 
to  be  mistaken  for  the  head  of  the  fibula,  which  error  will  locate  the  linear 
guide  too  far  to  the  inner  side  of  the  leg,  and  cause  the  incision  to  be 
made  over  the  belly  of  the  tibialis  anticus  muscle.  To  avoid  this  error  it 
must  be  remembered  that  the  head  of  the  fibula  is  more  posteriorly,  and 
constitutes  the  most  external  bony  prominence  at  this  part  of  the  limb. 

The  septum  between  the  tibialis  anticus  and  the  extensor  longus  digi- 
torum may  be  indistinct  or  absent;  then  the  outer  border  of  the  tibialis 
anticus  muscle  should  be  sought  for  and  determined — 1,  by  the  forcible  ex- 
tension of  the  tarsus ;  2,  by  the  resistance  to  lateral  pressure ;  3,  by  the  line 


Fig.  199.— Transverse  section  at  upper  third  of 
right  leg. 
Anterior  tibial  artery  and  veins.  B.  Anterior  tibial 
nerve.  C.  Internal  saphenous  vein.  D.  Internal 
saphenous  nerve.  E.  Posterior  tibial  artery,  veins, 
and  nerve.  F.  Tendon  of  plantaris.  G.  External 
saphenous  vein.  H.  Short  saphenous  nerve.  I.  Ex- 
ternal cutaneous  nerve.     J.  Perineal  nerve. 


THE  LIGATURE  OF  ARTERIES. 


153 


indicating  the  interspace  which  may  be  seen  at  the  lower  extremity  of  the 
incision  when  invisible  above. 

The  anterior  tibial  artery  may  be  rudimentary  or  absent ;  it  may  run 
more  superficially  than  common.  So  long,  however,  as  it  keeps  in  the 
proper  line  the  pulsations  will  lead  to  its  detection. 

The  veu£e  comites  cling  so  closely  to  the  vessel  that  persistent  efforts  at 
separation  almost  invariably  lacerate  the  veins,  and  therefore  it  is  better,  on 
the  whole,  that  they  be  tied  along  with  the  artery  than  that  the  efforts  of 
separation  be  prolonged. 

Ligature  of  the  Dorsalis  Pedis  Artery.  The  Anatomical  Points.— This 
vessel  is  a  continuation  of  the  anterior  tibial  (Fig.  202) .  It  begins  at  the  ankle 
joint  and  passes  downward  between  the  metatarsal  bones  of  the  great  and  sec- 
ond toes.  The  dorsalis  pedis  is  tied  in  but  one  situation,  which  is  on  the  lin- 
ear guide  directly  continuous  with  that  of  the  anterior  tibial  artery  (Fig.  198). 

The  muscular  guide  is  the  outer  border  of  the  tendon  of  the  extensor 
proprius  hallucis  (Fig.  202). 

Tlie  Operation. — Extend  the  tarsus  and  forcibly  flex  the  great  toe  to 
make  prominent  the  tendon  of  the  extensor  proprius  hallucis ;  make  an  inci- 
sion about  three  inches  in 
length  along  the  outer 
border  of  this  muscle,  com- 
mencing at  the  bend  of  the 
ankle ;  divide  the  fascia 
and  expose  the  fleshy  inner 
portion  of  the  extensor 
brevis  digitorum  muscle ; 
draw  the  muscle  outward, 
when  the  artery  and  its 
satellite  veins  will  appear ; 
separate  the  artery  from 
the  veins,  and  pass  the 
needle  as  best  suits  the  con- 
venience of  the  operator. 

The  Fallacy. — The  ar- 
tery may  pass  outside  of 
the  line  indicating  its 
proper  course. 

Ligature  of  the  Poste- 
rior Tibial  Artery.— The 
posterior  tibial  artery  is 
sometimes  ruptured  in 
fracture  of  the  tibia. 

The  Anatomical  Points. 
— The  posterior  tibial  is  an 
artery  of  considerable  size 

which  comes  from  the  popliteal  at  the  lower  border  of  the  popliteus  muscle. 
It  passes  obliquely  to  the  tibial  side  of  the  leg,  there  goes  downward  between 


Pig.  200.— Transverse  section  of  right  leg  at  ' 
middle  third. 
A.  Extensor  proprius  hallucis.  B.  Anterior  tibial  artery, 
veins,  and  nerve.  C.  Posterior  tibial  arterv.  veins, 
and  nerve.  D.  Flexor  longus  digitorum.  E.  Inter- 
nal saphenous  vein.  F.  Internal  saphenous  nerve. 
G.  Tendon  of  plantaris.  H.  External  saphenous 
vein.  /.  Muscular  branches.  J.  Peroneal  artery 
and  veins.     A'.  Flexor  longus  hallucis. 


154 


OPERATIVE  SUEGERY. 


the  superficial  and  deep  layers  of  muscles  to  a  point  midway  between  the 
internal  malleolus  and  inner  tuberosity  of  the  os  calcis,  terminating  a  little 
further  on  in  the  external  and  internal  plantar  arteries. 

The  linear  guide  to  the  vessel  is  drawn  from  the  middle  of  the  popliteal 
space  to  midway  between  the  inner  malleolus  and  the  tuberosity  of  the  os 
calcis.  This  guide  is  not  a  feasible  one,  since  to  reach  the  artery  by  cutting 
upon  the  guide  necessitates  the  division  of  the  fibers  of  the  muscles  of  the 
calf  of  the  leg. 

The  linear  guide  to  the  operation  is  a  line  located  three  fourths  of  an 
inch  behind  the  internal  border  of  the  tibia  at  the  middle  and  lower  thirds 
of  the  leg  (Fig.  203).. 

The  Muscular  Guide. — At  the  middle  third  the  artery  lies  beneath  the 
soleus ;  at  the  lower  third,  to  the  outer  border  of  the  flexor  longus  digi- 
torum.  It  may  le  ligatured  at  three  situations :  at  the  middle  third,  at 
the  lower  third,  and  as  it  passes  behind  the  inner  malleolus. 

The  Operation  at  the  Middle  Third  (Fig.  203,  a). — Place  the  patient  on 
the  back,  flex  the  leg  on  the  thigh  and  the  thigh  on  the  pelvis,  rotating 

the  thigh  outward  so  that  the  leg  will 
lie  on  the  outer  side.  Make  an  incision 
on  the  linear  guide  to  the  operation  about 
four  inches  in  length ;  divide  the  deep 
fascia,  recognize  the  inner  border  of  the 
gastrocnemius,  beneath  which  will  be 
seen  the  fibers  of  the  soleus,  which  should 
be  divided  carefully  transversely  or  longi- 
tudinally— the  latter  preferable — down  to 
the  pale  yellow  aponeurosis  on  its  under 
surface ;  draw  apart  the  fibers  of  the 
soleus,  and  make  an  opening  through  the 
aponeurosis  about  an  inch  and  a  half 
from  the  inner  border  of  the  tibia,  of 
sufficient  size  to  expose  the  artery,  which 
is  found  beneath  attended  by  its  veins 
and  the  posterior  tibial  nerve  (Fig.  200) ; 
draw  the  nerve  to  the  outer  side,  separate 
the  vessel  from  the  veins,  and  pass  the 
needle  from  without  inward. 

The  Operation  at  the  Loioer  Third 
(Fig.  203, 1)). — Place  the  limb  as  before; 
make  an  incision  in  the  course  of  the 
linear  guide  about  three  inches  in  length  ; 
divide  the  integument  and  fascia  in  the 
usual  manner ;  separate  the  borders  of  the  wound,  then  divide  the  aponeu- 
rosis (which  binds  down  the  deep  layer  of  muscles)  at  about  one  inch 
from  the  internal  border  of  the  tibia,  push  aside  the  fat,  and  the  vessel 
with  its  nerve  and  veins  will  be  found  at  the  outer  border  of  the  flexor 
longus  digitorum  (Fig.  201);   separate  the  artery  from  the  veins  if  prac- 


FiG.  201. — Transverse  section  through 
right  leg  at  lower  third. 

A.  Musculo-cutaneous  nerve.  B.  Pero- 
neal artery  and  veins.  C.  Peroneus 
longus.  D.  External  saphenous  vein. 
E.  External  saphenous  nerve.  F. 
Tendo  Achillis.  &.  Tendon  of  plan- 
taris.  H.  Posterior  tibial  artery, 
veins,  and  nerve.  /.  Internal  saph- 
enous vein.  J.  Internal  saphenous 
nerve.  K.  Anterior  tibial  artery, 
veins,  and  nerve. 


THE  LIGATURE  OF  ARTERIES. 


155 


ticable,  push  the  nerve  to  the  outer  side,  and  pass  the  needle  from  with- 
out inward. 

The  Operation  hetiveen  tlie  Os  Calcis  and  Internal  Malleolus. — Place 
the  foot  on  its  outer  surface  and  make  a  curved  incision  about  three  inches 
in  length,  with  the  concavity  uppermost 
and  the  center  at  a  point  midway  between 
the  malleolus  and  the  inner  tuberosity  of 
the  OS  calcis  (Fig.  203,  c).  Divide  the 
fascia  and  the  internal  annular  ligament 
on  a  director,  using  caution,  since  the 
artery  lies  directly  beneath  the  ligament ; 
isolate  the  vessel  from  the  veins,  and  pass 
the  needle  from  without  inward.  In 
going  through  the  superficial  tissues, 
small  branches  of  the  saphenous  vein  will 
be  divided  unless  care  be  taken.  In  old 
people  both  these  and  the  veufe  comites 
often  become  varicose,  which  condition 
increases  the  difficulty  of  finding  and  iso- 
lating the  artery.  It  is  better  not  to  at- 
tempt to  ligature  the  artery  in  this  situa- 
tion if  marked  evidence  of  varicosities  are 
present. 

The  Fallacies. — The  posterior  tibial 
may  be  double,  rudimentary,  or  absent. 
In  either  instance  the  peroneal  is  usually 
increased  in  size.  If  the  veins  are  closely 
associated  with  the  artery  they  should  be 
tied  along  with  that  vessel.  Carefully 
avoid  opening  the  sheaths  of  the  tendons 
that  are  contiguous  to  the  vessel. 

Ligature  of  tlie  Peroneal  Artery. — 
The  peroneal  artery  is  rarely  ligatured 
except  at  the  seat  of  the  injury  demand- 
ing it. 

The  Anatomical  Points. — The  peroneal  artery  arises  from  the  posterior 
tibial  at  about  one  inch  below  the  popliteus  muscle,  passes  obliquely  outward 
to  the  inner  border  of  the  fibula  (Figs.  194  and  195),  along  which  it  de- 
scends to  the  lower  third  of  the  leg,  and  is  finally  distributed  to  the  outer  side 
of  the  ankle.    It  may  be  ligatured  at  the  middle  and  at  lower  thirds  of  the  leg. 

TJie  linear  guide  to  the  vessel  is  a  line  drawn  from  the  posterior  border 
of  the  head  of  the  fibula  (Fig.  201,  *)  to  the  external  border  of  the  tendo 
Achillis  at  its  insertion. 

The  Operation. — Extend  the  foot  and  make  an  incision  about  four 
inches  in  length  along  the  guiding  line  parallel  with  the  external  border  of 
the  fibula  (Fig.  201,  a).  Separate  the  attachments  of  the  soleus  and  the  flexor 
longus  hallucis  from  each  other,  and  the  artery  will  be  found  at  the  inner  side 


Fig.  203. — Ligature  of  dorsalis  pedis 
arteay. 


156 


OPERATIVE  SURGERY. 


Fig.  203. — Ligature  of  posterior  tibial  artery. 
a.  At  middle  third,     b.  At  lower  third,     c.  Between  os  calcis  and  internal  malleolus. 


THE   LIGATURE  OF   ARTERIES. 


157 


^CUT   SURFACE  Of  SOLEUS. 
GASTROCNEMIUS  (OUTER  EDGEl- 


LcUT  SURFACE   OF'  SOLEUS. 


.CUT  SURFACE  OF  FLEXOR  LONGUS  HALLUCIS . 
.FLEXOR    LONGUS   HALLUCIS. 


Fig.  204. — Ligature  of  peroneal  artery. 
a.  At  middle  third,     b.  At  lower  third,     c.  The  saphenous  nerve  and  vein. 


158 


OPERATIVE  SURGERY. 


of  the  flexor  longus  hallucis  close  to  the  fibula.  The  venae  comites  may  be 
included  in  the  ligature. 

The  Fallacies. — The  peroneal  artery  is  rarely  absent.  It  may  be  over- 
looked, and  the  posterior  tibial  tied  instead.  If  its  close  relation  to  the 
fibula  be  remembered  this  mistake  will  not  occur. 

Ligature  of  the  Innominate  Artery. — The  innominate  artery  is  invested 
with  great  significance  on  account  of  its  relation  to  aneurism  and  its  resist- 
ance of  the  curative  efEects  of  the  ablest  surgical  endeavor. 

TJie  Anatomical  Points. — The  innominate  artery  arises  from  the  begin- 
ning of  the  transverse  arch  of  the  aorta  in  front  of  the  left  common  carotid, 
passes  obliquely  upward  and  outward  to  the  upper  border  of  the  right  sterno- 
clavicular articulation,  where  it  divides  into  the  right  common  carotid  and 
right  subclavian  arteries. 

The  Contiguous  Anatomy. 

The  Relations  op  the  Innominate  Artery.    (Gray.) 

/w  front. 
Sternum. 

Sterno-hyoid  and  sterno-thyroid  muscles. 
Remains  of  thymus  gland. 

Left  innominate  and  right  inferior  thyroid  veins. 
Inferior  cervical  cardiac  branch  from  right  pneumogastric  nerve. 


Right  side. 

Left  side. 

Right  vena  innominata. 

3  Innominate 
]       artery. 

\ 

Remains  of  thymus. 

Right  pneumogastric  nerve. 

Left  carotid. 

Pleura. 

Behind. 
Trachea. 

Left  inferior  thyroid  vein, 
Trachea. 

While  this  vessel  has  no  practical  linear  or  muscular  guides,  still  a  line 
drawn  from  the  junction  of  the  first  two  pieces  of  the  sternum  to  the  right 
sterno-clavicular  articulation  indicates  the  substernal  course  of  the  vessel. 
However,  it  should  not  be  forgotten  that  this  course  is  not  an  invariable 
one,  for  in  many  instances  it  bifurcates  above  or  below  this  point,  more  fre- 
quently at  the  latter  situation. 

The  remaining  guides  to  the  vessel  are  the  trachea,  common  carotid,  and 
subclavian  arteries.  The  trachea  lies  immediately  behind  the  artery  and  is 
crossed  obliquely  by  it.  The  carotid  and  subclavian  arteries  lead  down  to 
the  point  of  the  bifurcation  of  the  innominate. 

Numerous  incisions  are  described  for  gaining  access  to  the  vessel.  The 
one  limited  to  the  soft  parts,  which  is  best  calculated  to  afford  the  greatest 
amount  of  room,  was  employed  in  1818  by  the  late  Valentine  Mott,  when  the 
vessel  was  ligated  first.    Eesection  of  sternum  is  practiced  in  same  methods. 

The  Operation. — Place  the  patient  on  the  back,  with  the  shoulders  some- 
what raised  and  the  head  turned  backward  and  to  the  left  side.  This  posi- 
tion draws  the  artery  upward  from  behind  the  sternum.  An  incision  is  then 
made  three  inches  in  length,  extending  along  the  upper  border  of  the  clavicle 
to  opposite  the  center  of  the  episternal  notch,  which  is  joined  by  another  of 


THE  LIGATURE   OF  ARTERIES. 


159 


similar  length  directed  along  the  anterior  portion  of  the  sterno-mastoid  mus- 
cle (Fig.  205,  d).  The  triangular  flaj:)  thus  formed,  consisting  of  the  integu- 
ment, superficial  fascia,  and  platysma,  is  turned  upward  and  outward.  The 
portions  of  the  sterno-cleido-mastoid  muscle  corresponding  to  the  horizon- 
tal incision,  and  the  sterno-hyoid  and  sterno-thyroid  muscles,  are  divided 
on  a  director  and  turned 
aside.  The  inferior  thy- 
roid veins,  if  they  now 
come  into  view,  are  cau- 
tiously drawn  aside,  the 
deep  cervical  fascia  is 
torn  or  cut  through,  and 
the  sheath  containing  the 
common  carotid  artery, 
pnemnogastric  nerve,  and 
internal  jugular  vein  is 
brought  into  view.  Open 
the  carotid  compartment 
of  the  sheath,  draw  the 
vein  and  nerve  to  the 
outer  side,  and  follow  the 
carotid  down  to  the  sub- 
clavian, the  origin  of 
which  should  be  prompt- 
ly exposed.  The  upper 
portion     of     the     innom- 

inata  is  then  separated  from  its  important  connections  by  the  finger  or  a 
blunt  director;  the  left  vena  innominata  is  depressed,  and  the  right  vena 
innominata,  right  internal  jugular,  and  the  pneumogastric  nerve  are  carried 
to  the  right,  and  the  aneurism  needle  is  passed  from  below  upward,  and 
from  behind  forward  and  inward,  in  close  contact  with  the  vessel  (Fig. 


X 


Fig.  205. — Linear  guides,  a.  For  ligature  of  external 
carotid,  b.  For  ligature  of  common  carotid,  c.  For 
ligature  of  vertebral,  d.  For  ligature  of  innominate 
(Mott).  e.  For  same  (Kocher).  /.  For  same  (Bar- 
denheuer).  g.  For  ligatui-e  of  subclavian  below 
clavicle,  h.  For  ligature  of  internal  mammary. 
^.  For  ligature  of  subclavian  above  clavicle. 


BRACHIAL  PLEXUS 
TRANSVERSALIS  COLLI  A 
TRAPEZIUS  M 


ANTERIOR    SCA^EIJ 
SUPRA-SCAPULAR  A 

CUT  END  OF  CLAVICLE 


ft 

^Ijj-THYROID  GLAND. 

STERfJO- MASTOID  M. 

TRACHEA. 

STERm-MASTOID  M. 


i.SUBCLAVMN^->'^-^ 


r 


Fig.  206. — Right  subclavian  and  innominate  arteries. 

206).  It  is  thought  that  cutting  away  the  sternum  will  better  preserve 
the  nutritive  integrity  of  the  coats  of  the  vessel  by  leaving  its  vas- 
cular connection  with  the  sheaths  undisturbed  above.  Kocher's  incision  (a) 


160  OPERATIVE  SURGERY. 

begins  at  the  junction  of  the  lower  and  middle  thirds  of  the  anterior  border 
of  the  sterno-mastoid  and  passes  downward  in  a  slightly  curved  manner  and 
terminates  on  the  anterior  surface  of  the  first  portion  of  the  sternum. 

Ligature  tvith  resection  of  the  sterno-clavicular  articulation  and  the  upper 
end  of  the  sternum,  although  suggested  some  years  before  and  practiced  by 
Cooper,  Bardenhauer,  and  the  author  on  the  cadaver,  was  not  practiced  on 
the  living  subject  until  1895,  when  Burrell,  of  Boston,  carried  it  into  effect 
with  eminent  success— a  success  emphasized  by  the  fact  that  the  patient  re- 
covered, lived  one  hundred  and  four  days,  and  then  died  suddenly  from 
chronic  heart  disease  and  arterial  sclerosis.  On  account  of  the  importance 
of  the  case,  liberal  quotations  will  be  made  from  the  report  of  Dr.  Burrell 
(Transactions  of  the  American  Surgical  Association,  vol.  xiii,  1895). 

The  Operation. — "  An  incision  was  made  at  the  anterior  edge  of  the  right 
sterno-cleido-mastoid  muscle  extending  from  the  level  of  the  cricoid  carti- 
lage to  two  inches  below  the  upper  border  of  the  sternum.  From  this  point 
another  incision  extended  outward  four  inches  in  length  to  the  junction  of 
the  outer  and  middle  thirds  of  the  clavicle.  This  skin-flap  with  the  fascia 
and  platysma  muscle  was  turned  back.  The  sterno-mastoid  was  severed  close 
to  its  insertion  into  the  clavicle  and  sternum.  The  sterno-thyroid,  sterno- 
hyoid, and  omo-hyoid  muscles  were  also  divided.  This  brought  to  view  a 
fusiform  aneurism  in  the  right  subclavian  and  right  carotid  arteries,  extend- 
ing down  and  on  to  the  innominate.  It  was  believed  that  enough  of  the 
innominate  could  be  exposed  to  place  a  ligature  between  this  fusiform  aneu- 
rism and  the  aorta.  By  means  of  a  half-inch  trephine  operated  by  a  surgi- 
cal engine,  the  right  sterno-clavicular  articulation  and  the  right  half  of  the 
notch  of  the  sternum  for  about  an  inch  down  from  the  top  were  honey- 
combed. The  bony  parts  were  by  this  means  weakened,  and  the  removal  of 
the  articulation  and  the  piece  of  the  sternum  were  easily  completed  by  bone 
forceps.  A  flat  copper  retractor  was  slid  underneath  the  sterno-clavicular 
articulation  and  the  sternum  while  the  trephine  was  being  used  to  protect 
the  underlying  parts. 

"  When  this  block  of  bone  was  removed  there  was  exposed  the  right  in- 
nominate vein  and  the  left  innominate  vein  going  down  to  form  the  superior 
vena  cava,  with  the  vagus  and  recurrent  laryngeal  nerves  resting  on  the  in- 
nominate artery,  all  plainly  to  be  distinguished.  The  wound  at  this  time 
was  filled  with  bubbling  air,  which  had  been  sucked  into  the  areolar  tissue 
which  surrounds  the  great  vessels  at  the  base  of  the  neck.  Its  presence  was 
ominous,  and  it  was  felt  at  this  step  by  all  of  those  who  were  present  that  if 
any  large  vein  were  pricked  a  fatal  result  would  be  inevitable.  Precautions 
were  taken  to  prevent  the  entrance  of  air  by  keeping  the  wound  filled  with 
sterile  water. 

"  The  sheath  of  the  vessel  was  opened  and  the  innominate  artery  was 
isolated.  Then  came  the  problem  of  how  the  ligatures  should  be  passed. 
The  rule,  of  course,  is  to  pass  the  ligature  away  from  danger.  This  was  im- 
possible, owing  to  the  size  of  the  vessel  and  the  fact  that  it  was  surrounded 
by  important  structures  on  every  side.  The  separation  of  the  sheath  of  the 
artery  was  finally  completed  by  means  of  the  forefingers  placed  on  either 


THE  LIGATURE  OP  ARTERIES.  161 

side  of  the  vessel.  The  artery  was  estimated  to  be  an  inch  and  a  quarter 
in  circumference.  The  ordinary  curved  aneurism  needle  was  too  small  to 
pass  about  the  vessel,  and  the  blunt  point  of  the  aneurism  needle,  it  was 
felt,  might  wound  important  structures  posterior  to  the  vessel.  A  fiat  (three 
quarters  of  an  inch  in  width)  copper  spatula,  curved  on  itself,  was  passed 
about  the  vessel.  As  soon  as  this  copper  spatula  was  in  position  a  flat  braid- 
ed silk  ligature  was  passed  around  the  vessel  by  an  aneurism  needle  and  tied 
in  a  square  knot.  It  was  feared  that  the  extra  turn  in  the  first  part  of  a 
surgeon's  knot  might  tear  the  vessel.  Fully  three  minutes  were  taken  in  se- 
curing the  first  ligature.  Gradually  it  was  drawn  tighter  and  tighter  until 
the  circulation  was  completely  cut  off.  The  coats  of  the  vessels  were  felt  to 
give  way  while  tying  this  first  ligature,  which  was  placed  three  quarters  of 
an  inch  from  the  aorta. 

"  The  second  ligature  of  silk  was  placed  in  the  same  manner  one  half 
inch  higher  up,  but  was  not  drawn  as  tightly  as  the  other,  for  the  coats  were 
felt  to  give  way,  and  the  possibility  of  a  tear  of  the  innominate  artery  was 
recognized.  Both  ligatures  were  tied  in  square  knots  and  cut  short.  It 
was  my  intention  to  sever  the  innominate  artery  between  these  ligatures,  to 
place  the  vessel  at  rest  by  avoiding  the  tracheal  tug ;  but  the  size  of  the  ves- 
sel, and  the  feeling  that  came  to  my  fingers  while  tying  the  second  ligature 
that  the  artery  was  not  completely  closed  at  this  point,  led  me  to  give  up 
this  step  in  the  operation. 

"  The  overlying  muscles  were  sutured  in  approximately  their  original 
positions,  and  the  wound  was  closed  as  rapidly  as  possible.  An  aseptic 
dressing  was  applied.     The  operation  lasted  one  hour  and  a  half." 

Ligature  of  the  Innominate  Artery  (Bardenheuer's  Method) . — In  1885  * 
Bardenheuer  excised  a  portion  of  the  sternum  for  removal  of  a  tumour  of 
the  neck  encroaching  on  the  anterior  mediastinum.  The  facility  mth 
which  the  substernal  contents  were  exposed  suggested  to  him  the  expediency 
of  following  this  method  of  practice  in  securing  the  innominate. 

The  Operation. — Place  the  patient  as  in  Mott's  method  of  ligature  of 
the  vessel  (page  158),  make  a  vertical  incision  in  the  median  line  of  the 
neck  and  sternum  from  the  cricoid  cartilage  to  the  line  of  junction  of  the 
second  ribs  with  the  sternum — dividing  the  soft  parts,  including  the  deep 
cervical  fascia  (Fig.  205),  divide  through  a  transverse  incision  correspond- 
ing to  the  inner  thirds  of  the  clavicles  and  the  episternal  notch,  the  super- 
ficial soft  parts,  also  the  sternal  portions  of  the  sterno-mastoids,  both 
sterno-thyroid  and  sterno-hyoid  muscles;  resect  subperiosteally  a  half  inch 
of  the  inner  ends  of  the  right  clavicle  and  first  rib ;  raise  up  the  released 
border  of  the  sternum  sufficiently  to  permit  of  the  separation  of  the  peri- 
osteum from  the  upper  half  of  the  posterior  surface  of  the  manubrium; 
divide  transversely  the  manubrium  just  below  the  lower  border  of  the  first 
rib  with  a  Gigli-Haertel  saw;  separate  periosteally  the  left  clavicle,  the 
left  first  rib  from  the  sternum,  remove  the  bone  fragments  thus  formed 
and  incise  the  posterior  sternal  periosteum  in  the  median  line,  exposing 

*  Deutsche  med.  Wochenschrift,  1885,  40. 


162 


OPERATIVE  SURGERY. 


thereby  the  substernal  structures ;  ligature  the  small  veins,  and  depress  and 
pull  aside  cautiously  the  larger  ones  in  such  a  manner  as  to  suitably  expose 
the  innominate  for  tying. 

No  effort  is  made  to  return  and  secure  in  place  the  separated  bone. 
The  almost  certain  failure  to  unite  attended  with  the  danger  of  infection 


Pig.  207.— The  Ballance  and  Edmunds 
stay-knot,  floss  silk,  single  fold,  applied 
to  the  innominate. 


Fig.  208.— The  Ballance  and  Edmunds  stay- 
knot,  floss  silk,  completed  tie,  applied  to 
innominate  external  plaiting  of  vessel. 


and  its  influence  on  the  ligatured  vessel,  are  much  too  great  to  invite  the 
effort,  though  occasional  success  might  attend  the  attempt.  If  the  perios- 
teum have  not  been  disturbed,  the  bony  flap  attached  at  the  left  side  by 
means  of  the  soft  parts  can  be  turned  over  and  afterward  be  restored  and 
fastened  in  place  with  a  fair  chance  of  union  in  the  absence  of  infection. 
At  no  better  place  than  under  ligature  of  the  innominate  can  figures 

illustrative  of  the  Ballance  and  Ed- 
munds  stay-knot    (page   84)    be   in- 
troduced  and   for   reasons   too    obvi- 
fc^>     ous  to   require  mention    (Figs.    207, 
V       208,  209,  210). 


Fig.  209.— The  Ballance  and  Edmunds 
stay-knot,  floss  silk,  applied  to  in- 
nominate ;  knot  cut  showing  internal 
plaiting  of  vessel. 


Fig.  210.— The  Ballance  and  Edmunds 
stay-knot,  floss  silk,  applied  to  in- 
nominate, showing  internal  appear- 
ance at  seat  of  ligature. 


The  Remarks. — E.  S.  Cooper,  M.  D.,  of  San  Francisco,*  was  the  first 
to  resect  the  upper  portion  of  the  sternum  and  the  sternal  extremity  of  the 
clavicle,  in  order  to  reach  the  artery. 

The  patient  was  placed  upon  his  back,  with  the  head  and  shoulders  ele- 
vated, an  incision  four  inches  long,  in  a  line  parallel  with  and  half  an 


*  American  Journal  of  Medical  Sciences,  1859,  vol.  xxxviii. 


THE  LIGATURE  OF  ARTERIES.  163 

inch  above  the  upper  margin  of  the  clavicle,  commencing  internal  to  the 
sterno-clavicular  articulation,  and  terminating  near  the  anterior  margin  of 
the  trapezius  muscle,  was  made.  A  second  incision  was  then  made,  com- 
mencing a  little  to  the  inner  side  of  the  center  of  the  first,  extending  up- 
ward, external  to  the  sterno-cleido-mastoid  muscle,  and  terminating  two 
and  a  half  inches  above.  The  parts  were  dissected  away  to  expose  the 
tumor,  which  it  was  soon  ascertained  extended  beneath  the  clavicle,  and 
that  it  pressed  hard  upon  the  posterior  surface  of  the  summit  of  the 
sternum. 

After  long  trial  and  failure  to  make  room  for  the  application  of  a 
ligature  to  the  innominate  without  removing  important  structures.  Dr. 
Cooper  proceeded  to  remove  the  summit  of  the  sternum,  and  the  sternal 
extremity  of  the  clavicle,  which  barely  made  room  sufficient  to  enable  him 
to  reach  the  innominate,  owing  to  the  large  size  of  the  aneurismal  tumour 
at  that  point. 

In  fact,  one-third  of  the  innominate  was  already  dilated  by  the 
aneurism,  so  that  he  had  to  ligate  that  vessel  within  three-fourths  of  an 
inch  of  the  aorta.  The  patient  lost  but  little  blood  during  the  operation, 
and  was  comparatively  comfortable  for  five  days.  After  that  time  he 
became  restless,  had  dyspnoea,  retention  of  urine,  and  gradually  sank  until 
the  ninth,  when  he  expired. 

Ligature  of  the  Innominate  Artery  {Splitting  the  Manubrium). — In 
this  operation  the  manubrium  is  divided  transversely  and  vertically  with- 
out sacrifice  of  bone. 

The  Operation. — Place  the  patient  as  in  the  preceding  instances;  make 
a  continuous  curved  transverse  incision  corresponding  to  the  inner  thirds 
of  the  clavicles  and  the  line  of  junction  of  the  upper  and  middle  thirds 
of  the  manubrium  (Fig.  205)  ;  divide  the  soft  parts  through  this  incision 
down  to  the  bone,  tying  the  bleeding  points ;  reflect  from  the  anterior  sur- 
face of  the  manubrium  to  either  side  the  soft  parts ;  detach  the  fascia  from 
the  episternal  notch  outward  at  either  side  to  the  insertion  of  the  sterno- 
mastoid  muscles ;  separate  and  displace  downward  with  the  finger  from  the 
manubrium  the  structures  lying  immediately  beneath  it;  divide  the  manu- 
brium transversely  at  the  junction  of  the  upper  borders  of  the  second  ribs, 
also  vertically  through  the  center  with  a  Gigli-Haertel  saw;  retract  and 
confine  well  apart  the  halves  of  the  manubrium,  exposing  to  view  the  sub- 
sternal structures  at  this  situation;  push  to  the  left  the  overlying  tissues, 
exposing  the  inferior  thyroid  veins,  which  ligature,  divide,  and  push  apart, 
revealing  the  innominate  veins;  depress  the  left  innominate  vein,  draw 
forward  and  to  the  right  the  opposite  one  if  practicable;  note  the  rela- 
tions of  the  pleura  and  of  important  nerves;  expose  the  artery  sufficiently 
for  the  purpose  of  ligaturing;  pass  the  needle  from  the  pleura,  depositing 
the  ligature  as  far  from  the  aorta  as  practicable. 

In  the  preceding  description  the  subperiosteal  technique  is  not  prac- 
ticed, since  it  is  carried  out  effectively  in  associated  methods  of  ligature  of 
the  vessel.  This  plan  of  procedure  is  quicker  done,  with  less  contusion 
of  tissue,  and'  therefore  is  a  prompter  technique  than  the  subperiosteal 


164  OPERATIVE  SURGERY. 

method.  The  substernal  periosteum  affords  protection  to  undertying  struc- 
tures during  sternal  division,  and  also  afterward  in  instances  of  infection. 
The  splitting  of  the  entire  sternum,  as  advised  by  Milton  (page  1053)  for 
the  removal  of  tumors  and  foreign  bodies  of  the  anterior  mediastinum, 
seems  in  no  essential  respect  to  be  contra-indicated  when  applied  only  to 
the  upper  end  of  the  sternum  in  ligature  of  the  innominate. 

The  following  successful  ligature  of  the  innominate  by  Curtis  *  is  of 
unusual  interest  in  this  connection.  Because  of  the  great  importance  of  the 
successful  cases  this  one  is  submitted  substantially  as  reported  by  Dr.  Curtis. 

M.  A.,  fifty-five  years  of  age,  a  carpenter  by  trade,  born  in  Sweden, 
was  admitted  to  St.  Luke's  Hospital  in  ISTovember,  1899.  Examination 
revealed  a  hypertrophied  heart  with  a  double  murmur  over  the  aortic  valve 
and  a  systolic  murmur  at  the  apex.  All  the  arteries  were  enlarged  and 
hard,  especially  the  right  subclavian  and  axillary.  Under  the  right  clavicle 
was  a  swelling,  apparently  two  inches  in  diameter,  corresponding  to  the 
subclavian  artery,  having  a  true  expansile  pulsation  with  the  heart  systole, 
and  a  loud  systolic  bruit.  Deep  pressure  upon  the  first  part  of  the  sub- 
clavian arrested  the  pulsation.  The  right  axillary  artery  was  as  large  as  a 
man's  thumb  as  far  down  as  the  border  of  the  latissimus  dorsi.  The 
carotids  were  but  little  altered,  and  there  was  no  increased  pulsation  of  the 
first  part  of  the  right  subclavian. 

The  Operation  (Ether  narcosis,  December  2,  1899). 

1.  A  median  incision  was  made  from  the  larynx  to  the  middle  of  the 
sternum  or  lower,  dividing  the  skin  and  deep  fascia  above  and  the  peri- 
osteum also  below. 

2.  The  sterno-hyoid  and  sterno-thyroid  muscles  were  followed  down  to 
their  sternal  insertion,  retractors  placed  so  as  to  draw  the  soft  parts  at  the 
base  of  the  neck  widely  apart. 

3.  A  transverse  incision  was  made  through  the  periosteum  along  the 
upper  border  of  the  manubrium,  and  the  periosteum  and  muscles  detached 
from  the  posterior  surface  of  the  bone  by  blunt  elevators  and  the  finger 
as  far  as  could  be  reached. 

4.  The  ordinary  amputation-saw  was  then  applied  to  the  bone  in  the 
line  of  the  vertical  incision  in  the  periosteum,  the  soft  parts  in  the  neck  and 
those  behind  the  sternum  being  protected  by  flat  metal  strips.  The  saw 
was  held  with  its  point  turned  toward  the  neck  and  its  handle  toward  the 
ensiform  cartilage.  It  should  cut  most  deeply  above,  and  entirely  divide 
the  manubrium  at  its  upper  border,  the  cut  being  more  shallow  below,  and 
only  grooving  the  bone  at  its  lower  end.  This  obliquity  of  the  cut  necessi- 
tates the  long  skin  incision  which  has  been  described. 

5.  A  stout  chisel  was  then  applied  in  the  saw-cut  at  the  superior  bor- 
der of  the  manubrium,  and  the  thin  layer  of  undivided  bone  on  the  pos- 
terior surface  was  made  to  give  way  as  the  wedge  action  of  the  chisel  forces 
the  two  halves  apart. 

6.  The  skin  was  well  retracted,  a  transverse  incision  made  in  the  peri- 

*  Annals  of  Surgery,  vol.  xxxiv,  Oct.,  1901. 


THE   LIGATURE   OF   ARTERIES. 


165 


^ 


osteum  across  the  face  of  the  bone  at  the  lower  level  of  the  first  intercostal 
space,  and  the  chisel  was  applied  in  this  line,  directed  oblicj[uely  outward 
from   the   middle   line    on 
each  side,   so  as  to   divide  \ 

each  half   of  the   sternum  V 

in    two.      The    instrument  ' 

should  not  be  allowed  to 
cut  entirely  through  the 
bone  at  the  outer  border 
for  fear  of  injury  to  the 
pleura  or  internal  mam- 
mary artery.  Both  lie  a 
little  distance  from  the 
bone  (Fig.  211),  so  that 
the  danger  of  wounding 
them  is  not  great. 

7.  Strong  retractors 
were  then  inserted  in  the 
median  saw-cut,  and  with 
a  little  force  the  two  halves    Fig.  211.— The  upper  end  of  sternum  divided  and  re- 

.  tractea,  exposing  deep  muscles  and  periosteum,  also 

were    suthciently   separated  trachea  through  incision  between  muscles. 

to     allow     access     to     the 

periosteum,   which   was    carefully   incised    with    the    point    of   the    knife, 
beginning  above,  where  the  danger  of  damage  to  the  subjacent  parts  is  least. 

As  the  periosteum  was   di- 
\  vided  the  halves  of  the  bone 

\  were  more  widely  separated, 

I  '^  and   the   interval   gradually 

increased  from  an  inch  to 
nearly  twice  that  distance  as 
the    steady    strong    traction 
was  maintained  during  the 
operation.     A  separation  of 
three  centimeters  can  be  ob- 
tained in  any  case,  and  this 
is  abundant.     The  small  in- 
tercostal branches  of  the  in- 
^    ternal  mammary  artery  are 
somewhat  tortuous  and  suffi- 
ciently  long   to    allow    free 
Pig.  212. — Trachea,  innom'inate  artery,  arch  of  aoita    motion  of  the  bone  without 
and  left  innominate  vein  exposed.    Right  pneumo-    rpppivino-    inimrv        TIip    or, 
gastric  and  recurrent  laryngeal  noted.  receding    injur}.       ine    ap- 

;  '  pearance    of    the    floor    of 

the  wound  is  showm  in  the  sketch  from  the  cadaver  (Fig.  212). 

8.  The  muscles  and  fascia  were  then  divided  by  blunt  dissection,  or 
with  forceps  and  scissors,  in  the  median  line,  beginning  above,  double 
ligatures  being  applied  to  the  veins  which  cross  the  line  of  incision. 

13 


/ 


166  OPERATIVE  SURGERY. 

The  innominate  was  isolated,  and  a  double  heavy  chromicized  catgut 
ligature  was  passed  around  it  by  means  of  a  strong  pedicle  needle  shaped 
like  an  iliac  aneurism  needle.  The  two  threads  were  laid  side  by  side,  so 
as  to  make  flat  pressure,  but  were  tied  simultaneously,  and  not  according 
to  Ballance  and  Edmunds'  directions  (page  84),  for  the  artery  was  so 
large  and  tense  that  it  was  feared  the  catgut  would  break  if  tied  singly. 
While  tying  the  knot  the  artery  was  folded  in  on  itself  smoothly  by  the 
pressure  of  a  blunt  instrum.ent  in  the  loop,  so  as  to  avoid  crumpling  up  the 
wall,  and  the  knot  was  drawn  only  tightly  enough  to  arrest  pulsation,  and 
not  so  as  to  cut  the  internal  coat.  This  ligature  was  placed  about  three- 
quarters  of  an  inch  below  the  bifurcation.  A  single  ligature  of  catgut  of 
the  same  size  was  passed  through  the  same  opening  beneath  the  artery,  but 
tied  obliquely,  so  that  in  front  it  lay  about  a  quarter  of  an  inch  distally 
from  the  first.  This  ligature  was  pulled  a  little  tighter  than  the  first, 
but  not  so  as  to  cut  the  inner  coat.  It  had  been  intended  to  slip  this  liga- 
ture along  the  artery  farther  from  the  first,  but  this  intention  was  aban- 
doned for  fear  of  causing  too  great  separation  of  the  vessel  from  its  sheath. 
The  bone  was  allowed  to  return  to  its  position,  and  the  two  halves  united 
with  a  couple  of  silver-wire  sutures.  The  wound  was  closed  without  drain- 
age, except  at  the  lower  angle  between  the  skin  and  the  sternum,  where  a 
small  gauze  drain  was  inserted  because  of  the  rather  abundant  oozing  from 
the  divided  bone. 

Eecovery  was  marked  by  disquieting  symptoms,  a  temperature  of  102° 
F.  to  104°  F.  for  two  days,  a  leucocytosis  of  19,800  (6,200  before  opera- 
tion), great  restlessness,  and  much  pain  in  the  shoulder.  The  pulse  was 
relatively  slow  (106  to  118)  and  of  good  quality,  and  there  were  no  cere- 
bral symptoms ;  the  wound  healed  well,  except  that  it  became  somewhat  red 
at  the  upper  angle,  with  a  drop  of  pus  around  some  of  the  skin  sutures. 

January  15th,  six  weeks  after  the  operation,  a  small  abscess  formed 
in  the  upper  angle  of  the  scar  and  discharged  half  an  ounce  or  less  of 
pus,  and  left  a  sinus,  which  persisted  for  seven  weeks  longer.  Four  days 
after  the  ligation  a  very  slight  pulsation  was  observed  in  the  aneurism  and 
in  the  right  radial  artery.  Pulsation  in  the  carotid  returned  about  the 
same  time,  evidently  due  to  collateral  circulation.  In  January  there  was 
almost  no  pulsation  in  the  aneurism,  but  as  this  seemed  to  be  increasing 
later,  it  was  determined  to  apply  additional  ligatures. 

Accordingly,  on  March  13,  1900,  under  ether,  an  incision  was  made 
along  the  inner  border  of  the  sterno-mastoid  muscle  and  the  common 
carotid  exposed.  No  pulsation  was  observed  in  the  lower  part. of  the  ves- 
sel, which  appeared  full  of  solid  blood-clot,  but  for  safety  a  ligature  was 
placed  around  it  and  tied  without  dividing  the  coats  of  the  vessel.  An- 
other incision  was  made  along  the  clavicle  from  the  lower  end  of  the  first, 
and  a  third  obliquely  downward  and  outward  from  the  same  point.  The 
clavicle  was  thus  exposed  and  divided  between  the  inner  and  middle  thirds 
with  a  Gigli  wire  saw.  The  first  part  of  the  subclavian  was  thus  brought 
into  view,  and  found  to  have  a  faint  but  decided  pulsation.  A  ligature  was 
applied  to  the  first  part  of  the  subclavian  just  beyond  the  thyroid  axis. 


THE  LIGATURE   OF  ARTERIES.  167 

This  arrested  pulsation  in  the  sac,  but  it  continued  in  the  first  part  of  the 
subclavian.  Beyond  the  ligature  (distally)  was  a  small  vertical  branch, 
which  was  assumed  to  be  an  irregular  vertebral,  although  it  was  small  and 
did  not  pulsate.  Another  ligature  was  thrown  around  the  subclavian  just 
beyond  (distal  to)  this  branch.  No  vertebral  artery  could  be  found  arising 
centrally  to  the  thyroid  axis,  and  it  was  believed  that  the  remaining  pulsa- 
tion in  that  part  of  the  vessel  came  from  the  internal  mammar}^  artery. 

The  divided  clavicle  was  then  wired  and  the  wound  closed.  The  tem- 
perature rose  again  to  102°  F.,  and  there  was  considerable  pain,  and  super- 
ficial infection  developed  in  the  upper  angle.  A  sinus  formed  and  bur- 
rowed to  the  bone,  and  the  wire  had  to  be  removed. 

The  Remarls. — The  subject  from  which  this  sketch  was  made  shows  a 
rather  unusually  low  origin  of  the  recurrent  laryngeal  nerve.  In  the  case 
of  operation  for  ligature  of  the  innominate  described  the  nerves  were  not 
seen  at  all ;  and  even  in  a  ligature  of  the  first  part  of  the  subclavian  by  this 
method  I  do  not  believe  there  would  be  any  danger  to  the  recurrent  laryngeal 
nerve,  because  the  sheath  of  the  vessel  would  be  opened  as  soon  as  exposed, 
and  the  subsequent  manipulations  would  take  place  within  the  sheath  com- 
pletely separated  from  the  nerve.  In  applying  a  ligature  to  the  innominate 
artery,  it  should  not  be  forgotten  that  a  small  arteriole  sometimes  takes 
origin  from  that  vessel  on  its  posterior  surface,  which  might  give  trouble 
to  the  operator.  On  October  24,  1900,  the  patient  was  in  good  health,  with 
no  trace  of  the  aneurism,  and  a  strong,  although  not  bony,  union  of  the 
clavicle. 

Tlie  Fallacies. — If  the  innominata  be  shorter  than  usual,  the  lower  ex- 
tremity of  the  common  carotid  may  be  tied  instead.  If  the  aorta  arches  to 
the  right  side,  the  innominata  will  be  on  the  left  side  instead  of  the  right. 
The  General  Bemarhs. — Eigid  antiseptic  measures  should  characterize 
each  detail  of  the  preparation  for  the  operation,  and  also  the  operation  itself. 
The  wound  should  be  promptly  and  thoroughly  closed,  and  the  inner  sur- 
faces kept  cautiously  applied  to  each  other  by  means  of  graduated  compresses 
held  in  position,  if  need  be,  by  a  rubber  cushion.  The  pain  and  irritability  of 
the  patient  excited  by  the  operation  and  the  after-treatment  should  be  re- 
lieved by  hypodermics  of  morphin  given  at  regular  intervals  until  the  wound 
is  properly  healed.  The  use  of  a  broad  ligature,  so  tied  that  the  knot  shall 
not  cause  the  ligature  to  make  uneven  pressure  on  the  walls  of  the  vessel, 
appears  to  be  an  important  desideratum  and  one  difficult  of  attainment. 
The  ligature  should  be  surely  aseptic  and  be  aseptically  applied.  Irregular 
foldings  of  the  constricted  vessel  and  harmful  knot  pressure  should  be 
avoided.  The  use  of  two  or  more  strong  ligatures  so  applied  as  to  equal- 
ize as  much  as  possible  the  strain  of  the  blood-flow  is  a  wise  measure.  Firm 
approximation  of  the  walls  of  the  vessel  without  rupture,  by  means  of  strong 
ligatures  of  floss-silk  or  flat  braided  silk,  soft  kangaroo  tendon,  or  chromi- 
cized  catgut,  seems  at  this  time  to  be  the  best  plan  of  action.  A  small  liga- 
ture should  be  insinuated  between  the  tissues  with  the  use  of  little  force  and 
with  great  caution  to  prepare  the  way  and  for  use  in  drawing  the  larger 
and  permanent  one  into  place.    The  plans  of  approach  through  bony  chan- 


168  OPERATIVE   SURGERY. 

nels  are  no  doubt  the  better,  as  they  afford  the  opportunity  of  direct  attack 
and  careful  manipulation  under  close  inspection.  However,  the  ever-chang- 
ing relation  of  the  parts  dependent  on  the  modifications  of  disease  and  pres- 
sure effect  renders  it  well-nigh  impossible  to  do  more  than  speculate  con- 
cerning the  difficulties  one  will  meet.  A  drainage-tube  ought  not  to  be 
employed  at  all,  as  its  presence  invites  ulceration  of  the  contiguous  tissues 
and  the  establishment  of  a  sinus  in  the  course  of  its  placement.  Textile- 
fabric  drainage  only  is  proper  for  the  wound,  and  this  should  not  be  used 
except  when  the  attainment  of  primary  union  is  defeated  already. 

Simultaneous  ligature  of  the  common  carotid  along  with  the  innomi- 
nate, and  possibly  also  the  vertebral,  then  or  subsequently  appears  to  be  a 
justifiable  and  perhaps  necessary  step  of  the  procedure.  The  surgeon 
should  carefully  consult  the  experience  of  the  preceding  efforts  before  at- 
tempting the  operation,  as  by  such  means  only  can  the  lessons  of  the  past  be 
properly  utilized. 

The  Results. — Of  43  reported  cases,  36  died  and  7  recovered;  38  were 
done  for  aneurism,  of  which  32  died  and  6  recovered;  5  were  done  for 
haemorrhage,  1  recovered;  28  were  done  before  asepsis,  of  which  2  recov- 
ered; of  the  15  done  under  asepsis,  5  recovered;  35  were  done  by  simple 
incision,  and  in  8  either  clavicle  or  sternum,  or  both,  were  resected.  Of 
those  done  by  simple  incision,  30  died  and  5  recovered;  of  those  done  by 
bone  resection,  6  died  and  2  recovered  (Haubold). 

Ligature  of  the  Subclavian  Artery. — The  subclavian  artery  has  for  a  con- 
siderable time  afforded  a  field  replete  with  occasions  for  varying  surgical  en- 
deavor. 

The  Anatomical  Points. — The  subclavian  artery,  on  the  right  side,  arises 
from  the  arteria  innominata,  opposite  the  junction  of  the  right  clavicle  with 
the  sternum ;  on  the  left  side,  it  arises  from  the  arch  of  the  aorta.  These 
vessels,  therefore,  differ  in  the  first  part  of  their  course  in  length,  direction, 
and  in  relation  to  the  contiguous  anatomical  structures.  The  right  sub- 
clavian is  about  three,  and  the  left  about  four  inches  in  length,  and  each 
arches  upward  into  the  neck  to  the  level  of  the  sixth  cervical  vertebra. 
TJach  vessel  is  divided  into  three  portio?is :  the  first  portion  is  situated  be- 
tween the  origin  and  the  inner  border  of  the  scalenus  anticus  muscle,  the 
second  lies  immediately  behind  this  muscle,  and  the  third  is  limited  by  the 
outer  border  of  the  scalenus  anticus  and  the  lower  border  of  the  first  rib. 

The  Guides. — The  posterior  border  of  the  sterno-mastoid  muscle  is  the 
superficial  and  the  scalenus  anticus  the  deep  muscular  guide.  The  first  rib 
and  its  scalenus  tubercle  are  the  deep  bony  guides.  The  scalenus  anticus 
muscle  is  inserted  into  the  tubercle  of  the  first  rib,  and  the  tubercle  varies 
in  its  physical  characteristics,  being  sometimes  high  and  pointed  and  easily 
felt,  at  other  times  scarcely  discernible,  and  again  being  imperceptible. 

Either  artery  may  be  ligatured  at  any  one  of  its  portions. 

The  Ligature  of  the  First  Portion,  Left  Side. — This  division  has  no 
definite  superficial  linear  or  inuscular  guide.  The  inner  border  of  the  sca- 
lenus anticus  is  important  as  leading  to  and  being  the  outer  limit  of  this 
portion  of  the  vessel  which,  owing  to  its  origin  from  the  arch  of  the  aorta  and 


THE  LIGATURE  OP  ARTERIES. 


169 


its  great  depth,  is  almost  beyond  the  reach  of  a  ligature.    The  close  relation  of 
the  vessel  to  very  important  structures,  the  injury  of  which  may  be  more  grave 
than  the  condition  calling  for  ligature  of  the  vessel,  renders  the  performance 
of  the  operation  at  this  situation  difficult  and  of  questionable  expediency. 
The  Co7itiguous  Anatomy. 

The  Relations  of  First  Portion  of  Left  Subclavian  Artery.    (Gray.) 

In  front. 
Pleura  and  left  lung. 

Pneumogastric,  cardiac,  and  phrenic  nerves. 
Left  carotid  artery. 

Left  internal  jugular  and  innominate  veins. 
Sterno-thyroid,  sterno-hyoid,  and  sterno-mastoid  muscles. 

Outer  side. 
\  Left  subclavian  artery,  )  Pleura. 

1  first  portion.  S 


Inner  side. 
Trachea. 
(Esophagus. 
Thoracic  duct. 


Behind. 
(Esophagus  and  thoracic  duct. 
Inferior  cervical  ganglion  of  sympathetic. 
Longus  colli  muscle  and  vertebral  column. 

The  Operation. — Place  the  patient  on  the  back  with  the  head  extended 
and  turned  to  the  opposite  side,  the  left  shoulder  well  depressed;  make  an 
incision  three  inches  and  a  half  in  length  along  the  inner  border  of  the 
sterno-cleido-mastoid  down  to  the  sternum ;  another,  two  inches  and  a  half 
in  length  along  the  inner  extremity  of  the  clavicle,  meeting  the  former  near 
the  trachea.  It  is  seen  that  this  incision  is  substantially  the  same  as  that 
for  ligaturing  the  innominate  artery  (Fig.  205,  d).     The  flap,  consisting  of 


OMO-HYOID  M 

STERNO-THYROID  M 

STERNO-HYOID  M 

PNEUMOGASTRIC  N 

INTERNAL  JUGULAR 

THYROID  AXIS 

VERTEBRAL 

STERNAL  ORIGIN  OF 
STERNO-MASTOID  M 

LEFT  INNOMINATE  V 

THORACIC  DUCT 


STERNUM- 


SPINAL  ACCESSORY  N. 
SCALENUS  ANTICU5.M. 
SCALENUS  MED  I  US  M. 
LEVATOR  ANGULII  SCAPUL/E  M. 
PHRENIC  N. 
BRACHIAL   PLEXUS. 
INFERIOR  THYROID. 
TRANSVERSALIS  COLU  A. 

OMO-HYOID   M. 

SUPRA-SCAPULAR  A. 

SUBCLAVIAN  A  . 

3RD.P0RTI0N. 


^\TERNAL  JUGULAR    V. 
VERTEBRAL     V. 


I  CLAVICLE  AND 
\  TRAPEZIUS  M. 


SUBCLAVIAN   V. 

Fig.  213. — Left  subclavian  vein  and  artery. 

the  integument,  superficial  fascia,  and  platysma,  is  turned  aside ;  one  half 
of  the  clavicular  portion  of  the  sterno-mastoid  and  its  whole  sternal  portion 
are  then  divided  on  a  director,  bringing  into  view  the  sterno-hyoid  and 
sterno-thyroid  muscles,  and,  to  the  outer  side,  the  omo-hyoid.  The  sterno- 
thyroid and  sterno-hyoid  should  be  divided  with  great  care  after  being  liber- 
ated from  the  fascia  which  covers  them.     The  inner  edge  of  the  scalenus 


170  OPERATIVE  SURGERY. 

anticus  muscle  is  now  sought  for ;  when  found,  it  will  guide  the  finger 
directly  to  the  vessel.  The  important  contiguous  structures  are  now  drawn 
inward  and  pressed  away  from  the  artery,  using  great  caution  to  avoid  the 
thoracic  duct,  which  will  be  in  the  line  of  search,  as  it  goes  behind  the 
jugular  vein  at  its  junction  with  the  left  innominate  vein.  The  needle  is 
carefully  passed  from  before  backward.  The  great  depth  of  the  vessel  makes 
it  difficult  to  pass  the  common  needle,  therefore  the  one  with  the  adjustable 
extremity  (Fig.  177)  should  be  employed. 

The  Results. — This  portion  was  tied  by  Dr.  J.  Kearney  Eogers  in  1845 ; 
the  patient  died  from  secondary  haemorrhage  on  the  fifteenth  day.  It  has 
been  ligatured  successfully  by  Halsted  in  extirpation  of  a  tumor,  and  by 
Schumpert  for  cure  of  aneurism.* 

The  Ligature  of  the  First  Portion,  Right  Side.— The  inner  border  of  the 
anterior  scalenus  leads  to  this  portion  on  the  right  the  same  as  on  the  left 
side  of  the  body  (Figs.  206  and  207).    This  muscle  may  be  called,  there- 
fore, the  deep  muscular  guide  to  this  portion  of  the  artery. 
The  Contiguous  Anatomy. 
The  Relations  of  First  Portion  of  Right  Subclavian  Artery.    (Gray.) 

In  front. 
Integument  and  superficial  fascia. 
Platysma  and  deep  fascia. 
Clavicular  origin  of  sterno-mastoid  muscle. 
Sterno-hyoid  and  sterno-thyroid  muscles. 
Internal  jugular  and  vertebral  veins. 
Pneumogastric,  cardiac,  and  phrenic  nerves. 

Beneath. 
S  Right  subclavian  artery,  )  Pleura. 

1  first  portion.  ) 

Behind. 
Recurrent  laryngeal  nerve. 
Sympathetic  nerve. 
Longus  colli  muscle. 
Transverse  process  of  seventh  cervical  or  first  dorsal  vertebra. 

The  Operation. — The  position  of  the  head  and  neck  of  the  patient  are  re- 
versed in  the  operation,  but  the  primary  incisions  and  dissection  are  substanti- 
ally the  same  in  this  as  in  the  preceding  operation.  The  internal  jugular 
should  be  pressed  aside  and  the  needle  passed  from  below  upward,  and  from  be- 
fore backward,  carefully  avoiding  the  pleura,  recurrent  laryngeal,  and  phrenic 
nerves.  The  ligature  of  the  vertebral  and  internal  mammary  arteries  at  the 
same  time  will  lessen,  it  is  believed,  the  danger  of  secondary  haemorrhage. 

The  Fallacies. — The  right  subclavian  may  arise  from  the  arch  of  the  aorta, 
when  it  will  be  more  deeply  situated  ;  it  often  passes  behind  the  oesophagus,  or 
between  it  and  the  trachea.  As  at  the  left,  the  artery  may  perforate  the  scale- 
nus anticus  or  pass  in  front  of  it,  the  vein  being  behind.  It  may  rest  on  a  cer- 
vical rib  and  be  located  higher,  and  be  more  prominent  for  this  reason,  or  ex- 
tend an  inch  or  so  above  the  clavicle,  or  lie  behind  it  even.  The  supra-scapular 
artery  may  take  origin  from  the  third  portion  instead  of  from  the  thyroid  axis. 

*  Medical  Record,  September  3,  1898. 


THE   LIGATURE   OF  ARTERIES. 


171 


The  Results. — The  first  portion  has  been  ligatecl  twenty-one  times; 
nineteen  of  the  cases  proved  fatal,  of  which  eight  died  of  haemorrhage. 
Ckitton,  of  St.  Thomas's  Hospital,  cured  an  aneurism  of  the  third  portion  of 
the  subclavian  by  ligature  with  floss  silk  at  the  inner  border  of  the  scalenus 
anticus  of  the  first  portion,  followed  the  next  day  by  ligature  of  the  first 
portion  of  the  axillary  artery.* 

Curtis,  of  New  York,  reports  a  case  cured  by  ligature  with  two  strands  of 
catgut  drawn  sufficiently  tight  to  occlude  the  lumen  but  not  divide  the  inner 
coats  of  the  vessel. f 

The  Ligature  at  the  Third  Portion,  Either  Side. 

The  Contiguous  Anatomy. 

The  Relations  op  the  Third  Portion  of  Subclavian  Artery.    (Gray.) 

In  front. 
Integument  and  superficial  fascia. 
Platysma  and  deep  cervical  fascia. 

External  jugular,  supra-scapular,  and  transverse  cervical  vein. 
Descending  branches  of  cervical  plexus. 
Subclavius  muscle  and  supra-scapular  artery  and  clavicle. 


Above. 
Brachial  plexus. 
Omo-hyoid. 


Subclavian  artery, 
third  portion. 

Behind. 
Scalenus  medius. 


■  Below. 
First  rib. 


The  linear  guide  to  the  operation  upon  this  portion  of  the  vessel  at  either 
side  is  drawn  just  above  and  parallel  with  the  upper  border  of  the  clavicle, 
between  the  posterior  border  of  the 
sterno-cleido- mastoid  and  the  ante- 
rior border  of  the  trapezius  muscle, 
andfor  convenience  should  be  about 
four  inches  in  length  (Fig.  214:,  a). 

The  Muscular  Guides  to  the 
Artery,  Second  and  Third  Por- 
tions.— The  second  and  third  por- 
tions of  the  vessel  have  no  direct 
superficial  muscular  guide.  The 
deep  muscular  guide  is  the  outer 
border  of  the  scalenus  anticus. 
The  posterior  belly  of  the  omo- 
hyoid, while  not  in  close  contact 
with  the  artery,  serves  an  import- 
ant purpose  in  directing  the  atten- 
tion of  the  surgeon  to  the  artery. 
The  situation  of  the  outer  border 
of  the  scalenus  anticus  is  well  in- 


TRAPEZiUS  M. 


SPINAL-  , 
ACCESSORY  N 


5TERN0. 
MASTOID  M 


a 


!^^^ 


Fig.  214. — Linear  guides  to  arteries  and  spinal 
accessory  nerve,  a.  Subclavian  artery,  b. 
External  carotid,  c.  Facial,  d.  Temporal. 
e.  Occipital.    /.  Lingual  artery. 


*  Medico-Chirurgical  Transactions,  vol.  Ixxx,  1897. 
t  Annals  of  Surgery,  April,  1898,  p.  540. 


172 


OPERATIVE  SURGERY. 


dicated  by  the  lower  part  of  the  posterior  border  of  the  sterno-cleido- 
mastoid,  provided  the  latter  muscle  be  not  uncommonly  developed.  The 
junction  of  the  inner  two  inches  of  the  clavicle  with  its  outer  portion  is 

a  far   more  unvary- 

TPANSVERSALIS  COLLI  ARTERY      ^         SUPHA-SCAPULAR  VESSELS. 

SUBCLAVIAN  ARTERY 


omo'hyoid  muscle 
trapezius  muscle 
brachial  plexus 
clavicle(cut 

deltoid  muscle 
subclavian  vein 


PECTORALIS  MINOR 


(SCALENUS 
{ANTICUS 
I  MUSCLE 


STERNO- 
MASTOID 
MUSCLE 


PECTORALIS 
MAJOR 


Fig.  315. — Anatomy  of  the  third  portion  of  the  right  subcla- 
vian and  right  axillary  arteries. 


ing  indication  of  the 
approximate  deep  lo- 
cation of  the  outer 
border  of  the  sca- 
lenus anticus  than 
is  the  posterior  bor- 
der of  the  sterno- 
cleido-mastoid  mus- 
cle (Fig.  215). 

The  Bony  Guide. 
— The  tubercle  on 
the  first  rib,  into 
which  the  scalenus 
anticus  is  inserted,  is 
the  bony  guide  to 
the  vessel  here,  the 
artery  being  directly 
behind  it.  As  al- 
ready stated,  the  tubercle  varies  considerably  in  its  physical  characteristics. 
The  Operation.  Third  Portion. — Place  the  patient  on  the  back  with 
the  shoulders  elevated,  head  bent  backward  and  turned  to  the  oj^posite 
side.  Draw  the  shoulder  of  the  corresponding  side  firmly  downward  to 
the  side  of  the  patient,  and  retain  it  in  that  position.  Compress  the  ex- 
ternal jugular  vein  above  the  clavicle  long  enough  to  cause  its  distention, 
thereby  indicating  its  exact  situation.  The  integument  is  drawn  evenly 
downward  and  incised  upon  the  clavicle,  and  it  will,  when  allowed  to  retract, 
carry  the  incision  upward  to  its  proper  situation — half  an  inch  above  the 
clavicle  (Fig.  214,  a) ;  divide  the  superficial  fascia  and  platysma  on  a  director, 
being  careful  not  to  sever  the  external  jugular,  which  can  be  either  pulled 
aside  or  divided  between  two  ligatures.  The  supra-scapular  and  transverse 
cervical  veins  should  be  treated  in  the  same  manner.  The  omo-hyoid  is 
now  sought  for  and  drawn  upward,  if  necessary,  and  the  supra-scapular 
artery  avoided. 

The  deep  cervical  fascia  is  torn  asunder  by  the  director,  and  the  outer 
border  of  the  scalenus  anticus  felt  for  on  a  line  with  the  outer  margin  of 
the  sterno-cleido-mastoid,  if  the  latter  have  not  been  divided ;  if  so,  it 
should  be  located  as  described  under  the  head  of  Muscular  Guides  to  the 
Second  and  Third  Portions  of  the  Artery  (page  171) .  If  the  head  be  turned 
forcibly  to  the  opposite  side,  the  scalenus  anticus  will  be  made  tense  and  more 
prominent.  When  found,  the  muscle  is  followed  downward  along  the  outer 
border  to  the  tubercle  of  the  first  rib^  immediately  behind  which  the  pulsa- 
tion of  the  artery  is  felt.  The  vessel  is  now  carefully  exposed  and  the 
needle  passed  from  before  backward  (Figs.  215  and  216).     Great  caution 


THE  LIGATURE   OP   ARTERIES. 


173 


should  be  taken   not  to  interfere  with  the  subclavian  vein,  which   lies  in 
front  of  and  on  a  lower  plane  than  the  artery. 

Tlie  Fallacies. — The  sterno-cleido-mastoid  muscle  may  have  an  unusual 
breadth  of  origin  from  the  clavicle,  thereby  causing  the  incision  to  be  made 
too  far  posteriorly.  Attention  to  the  clavicular  measurement  (two  inches 
from  the  sternal  end)  will  prevent  this  error.  The  tubercle  on  the  anterior 
surface  of  a  transverse  process  of  one  of  the  lower  cervical  vertebrse  may 
be  mistaken  for  the  tubercle  of  the  first  rib.  This  mistake,  however,  is 
easily  rectified  by  remembering  that  the  first  rib  extends  downward  and  out- 
ward, and  that  neither  pulsation  nor  the  outline  of  the  scalenus  anticus  is 
found  contiguous  to  a  transverse  process.  The  tubercle  of  the  first  rib  may 
be  absent,  then  the  muscular  insertion  into  the  rib  must  be  relied  upon  as  a 
guide  to  the  vessel. 


STEBNO-MASTOIO  M 
SUBCLAVJAM  A 

SCALENUS  AMI.  M 


■BRACHIAL  PLEXUS. 
OMO-HYOID   M. 
PLAT YS MA    M. 


Fig.  216. — Subclavian  and  external  carotid  arteries. 


The  artery  may  perforate  the  scalenus  anticus  or  pass  in  front  of  it,  the 
vein  being  behind  the  muscle.  It  may  rest  on  a  cervical  rib  and  be  located 
higher,  and  be  more  prominent  for  this  reason.  It  may  extend  an  inch  or 
so  above  the  clavicle  or  lie  behind  it.  The  scapular  arteries  may  come  from 
the  third  portion  instead  of  the  thyroid  axis. 

The  artery  may  be  in  front  of  the  tubercle  and  the  vein  behind  it.  The 
pulsation,  as  well  as  the  anatomical  appearances,  will  determine  the  inter- 


174  OPERATIVE  SURGERY. 

change  of  situations.  The  inner  cord  of  the  brachial  plexus  may  be  mis- 
taken for  the  artery. 

Tlie  Results. — Of  276  cases,  142  died;  254  were  done  before  asepsis, 
with  137  deaths;  144  were  for  aneurism,  61  died;  99  for  hsemorrhage,  70 
died;  11  for  tumor,  6  died.  Of  23  done  under  asepsis,  5  died;  17  for 
aneurism,  5  died;  5  for  hsemorrhage,  none  died. 

The  Ligature  of  the  Second  Portion. — The  linear  and  miiscular  guides 
are  practically  similar  to  those  of  the  preceding  portion. 

The  Contiguous  Anatomy. 

The  Relations  of  Second  Portion  of  Subclavian  Arteey.    (Gray.) 

In  front. 
Integument  and  superficial  fascia. 
Platysma  and  deep  cervical  fascia. 
Sterno-mastoid. 
Scalenus  anticus. 
Phrenic  nerve. 
Subclavian  vein. 
Ahove.  j  Subclavian  artery,  )  Below. 

Brachial  plexus.  (      second  portion.     )  Pleura. 

Behind. 
Pleura  and  middle  scalenus. 

The  Operation. — The  steps  essential  to  arrive  at  the  proper  site  in  this 
instance  are  not  varied  from  those  given  for  the  third  portion  until  the 
outer  border  of  the  scalenus  anticus  is  well  determined;  the  phrenic  nerve 
and  subclavian  vein  should  then  be  pushed  aside  and  the  muscle  divided 
(Figs.  206  and  213),  when  the  retraction  of  its  fibres  will  expose  the  artery 
to  view.  The  needle  is  then  passed  as  before,  closely  hugging  the  artery  to 
avoid  the  pleura  below  and  posteriorly. 

The  Results. — Of  16  cases,  10  died;  of  13  before  asepsis,  9  died;  of  9 
for  aneurism,  5  died;  of  4  for  hsemorrhage,  all  died.  Three  were  done 
under  asepsis  for  hemorrhage,  with  1  death. 

Ligature  of  the  Vertebral  Artery. — The  vertebral  artery  is  rarely  tied. 

The  Anatomical  Points. — The  vertebral  artery  arises  from  the  upper  and 
back  part  of  the  first  portion  of  the  subclavian  artery  close  to  the  inner 
border  of  the  anterior  scalenus  muscle,  passes  directly  upward  along  the 
anterior  surface  of  the  vertebral  column,  and  enters  the  foramen  in  the  trans- 
verse process  of  the  sixth  cervical  vertebra.  It  then  ascends  through  the 
foramina  in  the  transverse  processes  of  all  the  vertebrae  above  this,  inclining 
outward  and  upward  between  the  transverse  process  of  the  axis  and  atlas, 
and  finally  runs  in  a  deep  groove  on  the  upper  surface  of  the  posterior  arch 
of  the  atlas,  and  ascending  pierces  the  posterior  occipito-atloid  ligament. 

The  Contiguous  Anatomy. 

The  Relations  of  the  Vertebral  Artery.     (Gray.) 
In  front. 
Internal  jugular  vein  and  its  sheath. 
Inferior  thyroid  artery. 
Thoracic  duct  (left  side). 

Aponeurosis  between  longus  colli  and  the  scalenus  anticus. 
Vertebral  vein. 


THE   LIGATURE   OF   ARTERIES. 


175 


Outer  side. 
Scalenus  anticus. 


Vertebral 
artery. 


Behind. 
Cervical  nerves. 
Vertebral  column. 


Inner  side. 
Longus  colli. 


The  linear  guide  to  the  artery  in  the  first  situation  is  drawn  from  the  junc- 
tion of  the  inner  fourth  with  the  outer  three  fourths  of  the  clavicle  to  the 
posterior  border  of  the  mastoid  process.  This  vessel  has  deep  muscular  and 
bony  guides.  The  deep  muscular  guide  is  the  inner  border  of  the  scalenus 
anticus,  because  the  artery  lies  between  it  and  the  longus  colli.  The  tuber- 
cle on  the  transverse  process  of  the  sixth  cervical  vertebra  is  the  direct  bony 
guide  to  the  vessel.  The  vessel  enters  this  process  at  a  point  just  below  the 
tubercle  and  the  inner  border  of  the  scalenus  anticus. 


MASSETER  M. 
FACIAL   V. 
FACIAL  A. 


PAROTIDBO 
MASSETERIC  FASCIA 

PLATYSMA  M. 


COM.  CAROTID  A 

DESCENDENS  NDNI  N. 
INI.  JUGULAR  V. 
LOflGOS  COLLI  M 


TRANS.PROCESS  OF 
1  Bin  CEflV.  WERT. 

(\j£RIEbri\l(cabotid) 
'      tubercle.       ' 


,    VERTEBRAL  A. 

^  THYROID  GLAND. 
INF.THYFIOID  A. 

•^CCURSARYNGEAL  /V, 
1   STERAIO-HYOID  M. 


Fig.  217. — The  common  carotid,  vertebral,  inf.  thyroid,  and  facial  arteries. 

The  vertebral  artery  can  be  ligatured  at  three  situations :  1,  before  enter- 
ing the  vertebral  canal ;  2,  between  the  atlas  and  axis ;  3,  between  the  atlas 
and  the  occipital  bone.  At  the  first  situation  about  an  inch  and  a  quarter 
in  length  of  the  vessel  is  available  for  ligaturing.  The  artery  can  be  tied 
at  the  first  situation  through  an  incision  made  either  behind  or  in  front  of 
the  sterno-mastoid.     The  former  is  practiced  more  frequently. 

The  Operation  at  First  Sitnation. — With  the  shoulders  raised  and  the 
head  turned  to  the  opposite  side  as  in  ligature  of  the  subclavian,  an  incision 
four  inches  in  length  is  made  through  the  superficial  tissues  along  the  poste- 
rior border  of  the  sterno-mastoid  down  to  the  clavicle.  This  incision  is 
carried  carefully  down  to  the  deep  cervical  fascia,  which  is  cautiously  divided. 
The  jugular  vein  in  its  sheath  and  the  sterno-mastoid  are  drawn  gently  to 
the  outer  side,  and,  if  necessary,  the  size  of  the  wound  is  increased  by  a  sufii- 


176  OPERATIVE  SURGERY. 

cient  division  of  the  fibers  of  the  clavicular  attachment  of  the  sterno- mastoid 
muscle  (Fig.  217).  The  deep  connective  tissue  is  separated  with  a  blunt 
instrument,  and  the  interval  between  the  scalenus  anticus  and  the  longus 
colli  muscles  is  sought  for.  The  head  is  now  flexed  sufficiently  to  permit 
the  borders  of  the  wound  to  be  drawn  widely  apart ;  deeper  structures  are 
carefully  drawn  asunder,  and  the  tubercle  of  the  sixth  cervical  vertebra  is 
located,  below  which  the  pulsations  of  the  artery  can  be  felt.  The  artery 
is  exposed,  and  the  needle  is  passed  from  within  outward.  The  inferior 
thyroid  artery,  vertebral  veins,  and  the  thoracic  duct  on  the  left  side  are  in 
front  of  the  artery  and  should  be  carefully  avoided.  An  incision  at  the  ante- 
rior border  of  the  sterno-mastoid  affords  inadequate  access  to  the  vessel. 

The  Precaution. — In  exposing  the  vessel  caution  is  exercised  to  prevent 
unnecessary  injury  of  the  sympathetic  nerve,  thus  avoiding  as  much  as  possible 
the  modification  (contraction)  of  the  corresponding  pupil.  It  is  proper  to 
say  that  contraction  of  the  pupil  is  so  certain  to  follow  ligature  of  the  vessel 
that  its  occurrence  is  regarded  as  evidence  of  successful  ligation. 

Mr.  Alexander,  whose  experience  in  tying  these  vessels  on  the  living  sub- 
ject is  greater  than  that  of  any  other  surgeon,  describes  his  method  of  oper- 
ating in  the  following  language  :  "  An  incision  three  or  four  inches  long 
is  made  in  an  upward  and  outward  direction  along  the  hollow  which  exists 
between  the  scalenus  anticus  and  the  sterno-mastoid  muscles.  The  incision 
should  begin  just  outside  and  on  a  level  with  the  point  where  the  external 
jugular  vein  dips  over  the  edge  of  the  sterno-mastoid  muscle,  or,  if  the  vein 
is  invisible,  about  half  an  inch  above  the  clavicle.  The  external  jugular  vein 
is  drawn  inward  with  the  sterno-mastoid  muscle.  The  connective  tissue 
now  appearing,  the  wound  is  opened  by  a  blunt  director,  until  the  scalenus 
anticus  muscle,  the  phrenic  nerve,  and  the  transverse  cervical  artery  are  seen. 
It  can  not  be  too  well  remembered  that  the  pleura  is  at  the  inner  side  of  the 
wound,  while  below  lies  the  subclavian  artery.  It  is  now  only  necessary  to 
separate  the  edges  of  the  scalenus  anticus  and  the  longus  colli  muscles  to  see 
the  vertebral  artery  lying  in  the  space  between  them.  The  artery  is  gener- 
ally completely  covered  by  the  vein,  which  is  drawn  aside  and  the  artery  is 
then  ligatured." 

At  the  second  situation  the  artery  lies  in  a  triangular  space  formed  by 
the  rectus  posticus  major  and  superior  and  inferior  oblique  muscles.  It  is 
covered  by  the  rectus  posticus  major  and  the  complexus  muscles. 

The  Operation  at  Second  Situation. — With  the  head  turned  to  the  oppo- 
site side  and  inclined  forward,  make  an  incision  three  inches  in  length 
along  the  posterior  border  of  the  sterno-mastoid,  beginning  half  an  inch  below 
the  mastoid  process.  A  second  incision  is  then  made,  beginning  at  the  upper 
fourth  of  the  first  one  and  carried  backward  and  downward  one  inch.  The 
splenius  muscle  appears  as  soon  as  the  integument  and  fascia  are  divided  and 
pulled  aside.  The  fibro-muscular  structure  of  the  splenius  is  divided,  its 
borders  separated,  the  layer  of  fat  that  now  appears  is  pushed  aside  by  the 
finger  or  handle  of  the  scalpel,  and  the  vessel  is  seen ;  its  branches  are  drawn 
aside  together  with  those  of  the  second  cervical  nerve,  the  artery  isolated, 
and  the  needle  passed  from  without  inward. 


THE  LIGATURE  OF  ARTERIES.  lYY 

At  the  third  situation  the  incisions  are  the  same  as  in  the  preceding 
method,  except  that  the  first  one  begins  half  an  inch  above  the  mastoid 
process  instead  of  half  an  inch  below  it.  The  skin,  fascia,  and  splenius  are 
divided  as  before,  the  occipital  artery  appears  at  the  upper  angle  of  the 
wound,  and  is  held  aside  ;  divide  the  aponeurosis  and  cellular  tissue,  sep- 
arate the  wound  borders,  enter  the  triangle,  separate  the  fatty  tissue,  and 
the  artery  will  be  exposed.     Pass  the  needle  from  behind  forward. 

The  Fallacy. — Th-e  vertebral  arteries  may  enter  the  transverse  processes 
of  the  fifth  cervical  vertebra,  instead  of  the  sixth. 

The  Results. — These  vessels  have  been  ligatured  forty-two  times,  in  thirty- 
six  of  which  three  died — one  each  from  hgemorrhage,  embolism,  and  pleurisy. 
When  done  for  the  cure  of  epilepsy,  about  twenty  per  cent  were  benefited, 
some  of  which  it  is  claimed  ultimately  recovered.  The  permanent  benefit 
derived  thus  far  in  such  cases  has  not  been  sufficient  to  warrant  the  adoption 
of  this  measure  for  the  treatment  of  epilepsy,  and  Dr.  Alexander  himself  has 
ceased  to  advocate  it  for  this  purpose. 

Ligature  of  the  Internal  Mammary  Artery. — The  internal  mammary  artery 
is  ligatured  most  frequently  in  connection  with  operations  on  the  ribs. 

The  Anatomical  Points. — The  internal  mammary  arises  from  the  first 
portion  of  the  subclavian.  It  descends  behind  the  internal  jugular  and  sub- 
clavian veins  to  the  inner  surface  of  the  anterior  wall  of  the  chest,  lying 
beneath  the  costal  cartilages  and  about  half  an  inch  from  the  margin  of  the 
sternum.     It  can  he  ligatiwed  in  any  of  the  five  upper  intercostal  spaces. 

The  Linear  Guide. — A  line  parallel  with  and  located  about  half  an  inch 
to  the  outer  side  of  the  sternum  is  a  fair  linear  indication  of  the  course  of 
the  artery.  At  this  situation  the  vessel  is  midway  between  the  borders  of 
the  costal  cartilages.     It  has  no  muscular  guide. 

The  Operation. — Make  an  incision  two  inches  in  length  along  the  upper 
border  of  a  costal  cartilage  and  rib.  The  iiitegument,  fascia,  and  pectoralis 
major  muscle  are  divided  down  to  the  intercostal  muscles.  Beneath  the  in- 
tercostal, surrounded  by  the  connective  tissue,  the  artery,  accompanied  by 
the  ven^  comites,  will  be  found.  The  vessel  is  isolated,  and  the  needle  care- 
fully passed  to  avoid  penetrating  the  pleura.  If  the  vessel  be  tied  in  the 
uppermost  intercostal  space,  a  single  vein  will  attend  it. 

Ligature  of  the  Inferior  Thyroid  Artery.— The  inferior  thyroid  artery  is 
ligatured  in  operations  on  the  thyroid  body. 

The  Anat07nical  Points. — The  inferior  thyroid  arises  from  the  thyroid 
axis,  and  passes  in  a  somewhat  irregular  course  upward  and  inward  behind 
the  sheath  of  the  common  carotid  and  internal  jugular  vein  to  the  thyroid 
body.  It  passes  in  front  of  the  vertebral  artery  and  the  longus  colli  mus- 
cle. The  middle  cervical  ganglion  rests  upon  it.  The  recurrent  laryngeal 
nerve  and  the  thoracic  duct  at  the  left  side  should  be  carefully  avoided. 

The  Contiguous  Anatomy. — In  front,  the  common  carotid  sheath  and 
its  contents,  and  the  sympathetic  nerve  ;  behind,  the  recurrent  laryngeal 
nerve,  the  oesophagus,  and  the  vertebral  artery  ;  at  the  left  side,  if  low  in 
the  neck,  carefully  avoid  the  thoracic  duct. 

The  linear  guide  to  the  operation  is  located  along  the  anterior  border  of 


178  OPERATIVE  SURGERY. 

the  sterno-mastoid,  as  for  ligature  of  the  common  carotid.  An  approximate 
tony  guide  to  the  vessel  is  the  body  of  the  fifth  cervical  vertebra,  opposite 
to  which  the  artery  enters  the  thyroid  structure. 

The  Operation. — Make  an  incision  three  inches  in  length  along  the  inner 
side  of  the  sterno-mastoid,  as  for  ligature  of  the  common  carotid.  The  car- 
otid sheath  and  its  contents,  along  with  the  sterno-mastoid,  are  drawn  out- 
ward and  the  artery  is  found  behind  the  carotid,  running  inward  near  the 
body  of  the  fifth  cervical  vertebra  (Fig.  217).  The  needle  is  passed  from 
within  outward,  carefully  avoiding  the  recurrent  laryngeal  nerve. 

The  Fallacies. — The  vessel  may  be  double  or  absent ;  it  may  arise  from 
the  vertebral  or  common  carotid. 

The  Results. — The  results  are  excellent,  as  no  dangers  attend  the  liga- 
turing other  than  those  incurred  by  the  manipulation  necessary  to  reach  the 
vessel. 

Ligature  of  the  Axillary  Artery. — The  axillary  artery  is  ligatured  for 
rupture  and  for  cure  of  aneurism  more  often  than  for  any  other  reasons. 

The  Anatomical  Points. — The  axillary  artery  begins  at  the  lower  bor- 
der of  the  first  rib  and  extends  to  the  lower  border  of  the  tendon  of  the 
latissimus  dorsi.  It  gives  origin  to  numerous  branches  and  is  intimately 
associated  with  the  brachial  plexus.  This  artery  may  he  tied  at  three  situa- 
tions— 1,  above  the  pectoralis  minor ;  2,  behind  ;  3,  below  that  muscle  (Fig. 
215).  The  first  and  last  situations,  however,  are  the  only  ones  at  which  the 
vessel  can  be  practically  secured  without  ligature  of  collateral  branches. 

The  Contiguous  Anatomy. 

The  Relations  of  the  First  Portion  of  the  Axillary  Artery.    (Gray.) 

In  front. 
Pectoralis  major. 
Costo-coracoid  membrane. 
External  anterior  thoracic  nerve. 
Acromio-thoracic  and  cephalic  veins. 

Outer  side.       '  \     Axillary      ^  Inner  side. 

Brachial  plexus.  )„    ar  ery,        r  A-jrillarv  vpin 

^  ( first  portion.  )  Axillary  vein. 

Behind. 
First  intercostal  space,  and  intercostal  muscle. 
Second  and  third  serration  of  serratus  magnus. 
Posterior  and  internal  anterior  thoracic  nerve. 

The  First  Portion. — There  is  no  linear  guide  to  the  vessel  at  this  por- 
tion. The  linear  guide  to  the  operation  is  located  about  half  an  inch  below 
the  lower  border  of  the  clavicle,  extending  from  within  an  inch  or  so  of  the 
sternal  extremity,  outward  three  or  four  inches. 

The  muscular  guides  are  superficial  and  deep.  The  former  is  the  space 
between  the  contiguous  borders  of  the  deltoid  and  pectoralis  major  muscles. 
The  latter  is  the  pectoralis  minor,  its  upper  border  indicating  the  first  por- 
tion, etc.,  as  before  stated.  The  vessel  is  rarely  tied  at  this  point  on  account 
of  the  great  depth  and  the  nearness  to  the  seat  of  ligature  of  collateral 
branches.     The  third  portion  of  the  subclavian  is  tied  instead. 


THE  LIGATURE  OF   ARTERIES. 


179 


^PECTORALIS  MAJOR, DIVIDED  IN  COURSE  OF  FIBERS 
(imE9C0RD  OF 
M    BRACHIAL  PLEXUS 


'[   ^7^--     THORACIC 

,U^        [branch 
\{deep  fascia  (costo- 
\c0rac0id  membrane) 

upper  border  of  pectoralis  minor. 
Fig.  218. — Ligature  of  axillary  artery  ;  first  portion. 


The  Operation. — Place  the  patient  upon  the  back,  with  the  head  turned 
to  the  opposite  side ;  elevate  the  shoulder,  and  carry  the  arm  a  little 
distance  from  the  side  of  the  chest.  Make  an  incision  about  four  inches 
in  length  on  the  linear  guide  through  the  integument,  fascia,  and  pla- 
tysma;  separate  the  fibers  of  the  pectoralis  major  from  the  deltoid,  or 
divide  those  of  the  former  muscle  the  full  length  of  the  wound  (Fig.  218)  ; 
tear  apart  the  costo-  * 

coracoid  fascia  at  .pectoralis major. divided  in  course  of  fibers  .cephalic  vein. 
the  upper  border  of 
the  pectoralis  minor 
muscle ;  bring  the 
arm  to  the  side  to 
relax  this  muscle, 
which  is  then  drawn 
outward  ;  displace 
the  areolar  tissue 
carefully  with  a  di- 
rector, then  the  vein 
will  be  seen,  which 
should  be  carried 
downward  and  in- 
ward with  a  blunt 
hook,  and  the  artery 
will  be  noticed  beneath  it  and  in  close  contact  with  the  inner  cord  of  the 
brachial  plexus,  which  lies  to  its  outer  side  and  above.  The  needle  is  then 
passed  from  below  upward.  The  cephalic  vein,  which  empties  into  the 
axillary  vein,  should  be  cautiously  avoided,  as  it  passes  between  the  borders 
of  the  pectoral  and  deltoid  muscles  to  its  termination. 

T7ie  Fallacies. — The  inner  cord  of  the  brachial  plexus  may  be  mis- 
taken for  the  artery.  If,  before  tightening  the  ligature,  pressure  be  made 
upon  the  vessel,  and  the  effect  upon  the  radial  pulse  noted,  this  fallacy  is 
eliminated. 

The  vessel  may  be  reached  through  an  incision  carried  between  the  del- 
toid and  pectoral  muscles  about  three  inches  in  length,  which  should  con- 
nect with  the  one  previously  made  at  the  lower  border  of  the  clavicle.  The 
fat  and  cellular  tissue  can  then  be  removed  or  displaced,  as  in  the  previous 
instance. 

The  Results. — No  definite  records  are  given  of  the  results  of  this  op- 
eration. 

The  Second  Portion. — The  artery  can  be  ligatured  at  this  situation 
through  the  preceding  incision,  or  through  the  space  created  by  separation 
of  the  contiguous  borders  of  the  deltoid  and  pectoral  muscles.  The  pec- 
toralis minor  is  exposed,  pulled  downward,  artery  isolated,  collateral  branches 
tied,  and  main  vessel  ligatured  in  the  usual  manner. 

Ligature  in  the  Third  Position. —  The  linear  guide  to  the  artery  at  this 
portion  is  a  dotted  line  extending  upward  into  the  axilla  corresponding  to 
the  junction  of  the  anterior  and  middle  thirds  of  this  space  (Fig.  219). 


180 


OPERATIVE  SURGERY. 


The  Contiguous  Anatomy. 
The  Relations  of  the  Third  Portion  of  the  Axillary  Artery.    (Q-rat.) 

In  front. 
Integument  and  fascia. 
Pectoralis  major. 
Inner  head  of  the  mediate  nerve. 
Outer  side.  Inner  side. 

Coraco-brachialis.  (       Axillary       ^        Ulnar  nerve. 

Median  nerve.  \         artery,         >       Internal  cutaneous  nerve. 

Musculo-cutaneous  nerve.  '  third  portion.  )       Axillary  vein. 

Behind. 

Subscapularis  muscle. 

Tendons  of  latissimus  dorsi  and  teres  major. 

Musculo-spiral  and  circumflex  nerves. 

The  Muscular  Guide. — The  inner  border  of  the  coraco-brachialis  muscle. 

The  Operation  (Fig.  219). — With  the  arm  abducted  and  rotated  out- 
ward, make  an  incision  three  inches  in  length  along  the  inner  border  of  the 
coraco-brachialis  muscle  in  line  of  the  arterial  pulsation,  observing  that  its 
center  be  placed  above  the  anterior  fold  of  the  axilla,  cautiously  divide  the 
superimposed  tissues,  draw  the  median  nerve  and  the  axillary  vein  to  the 
inner  side,  and  pass  the  needle  from  within  outward. 

The  Fallacies. — Large  branches  may  be  given  off  from  the  axillary  at 
this  situation,  which  will  confuse  the  operator  as  to  the  identity  of  the  ves- 
sel. Pressure  made  upon  the  vessel  with  the  fingers  prior  to  the  tightening 
of  the  ligature  will  determine  the  influence  of  pressure  on  the  circulation 
beyond.     A  nerve  may  be  mistaken  for  the  artery. 

The  Results. — The  results  are  favorable,  since  the  operation  implies  in 
itself  no  particular  danger  to  the  patient. 

Ligature  of  the  Brachial  Artery. — The  exposure  to  injury  of  the  bra- 
chial artery  calls  for  frequent  ligaturing  of  this  vessel. 

The  Anatomical  Points. — The  brachial  artery  extends  from  the  lower 
border  of  the  tendon  of  the  latissimus  dorsi  to  about  an  inch  below  the  bend 
of  the  elbow  joint,  and  is  closely  associated  with  the  veins  and  nerves  of 
the  arm. 

The  Contiguous  Anatomy. 

The  Relations  of  the  Brachial  Artery.    (Gray.) 
In  front. 
Integument  and  fascia. 
Bicipital  fascia,  median  basilic  vein. 
Median  nerve. 
Outer  side.  hmer  side. 

Median  nerve  (above).  h'  1  )        Internal  cutaneous  and  ulnar  nerve. 

Coraco-brachialis.  ]     ^^^   ^^    i        Median  nerve  (below). 

Biceps.  ^    artery.    )        Vena  comes. 

Yena  comes.  Basilic  vein  (upper  half). 

Behind. 
Triceps. 

Musculo-spiral  nerve. 
Superior  profunda  artery. 
Coraco-brachialis. 
Brachialis  anticus. 


THE  LTQATURE   OF  ARTERIES. 


181 


The  linear  guide  corresponds  to  the  dotted  Hue  extending  from  the 
junction  of  the  middle  and  anterior  thirds  of  the  axilla  to  midway  between 
the  apices  of  the  bony  condyles  of  the  humerus  (Fig.  319). 

The  Muscular  Guide.— Ki  its  upper  third  the  artery  lies  at  the  inner 
border  of  the  coraco-brachialis,  at  the  middle  third  at  the  inner  border  of 
the  biceps,  and  the  lower  third  it  lies  at  the  inner  border  of  the  biceps  ten- 


/  INNER  HEAD 
[OF  TRICEPS. 

j  INFERIOR 
^  1  PROrUNDA  A. 

^  ULNAR  N. 


MEDIAN 
BRACHIAL  A. 

INT.  CUTANEOUS    N. 
BICEPS  M. 
rULMAR  N. 
TRICEPS. 


MUSCULO-SPIRAL  N  % 
SUPERIOR  PROFUNDA  /[  '' 

BRANCH  TO  INNER  mO  OF  TR  CEP5 

LONE  HEAD  OF  TRICEPS 

TENDON  OF  LATISSIMUS DORSI 


AXILLARY  A  {3RD.  PARI.) 
-     MEDIAN  N. 

CORACO-BRACHIALIS  M. 

MUSCULO-CUTANEaUS  N. 

AXILLARY  V. 

ULNAR  N. 


virpng^l 


^Bl 


CIRCUMFLEX  N.  % 
SUBSCAPULAR  A.  '' 
LONB  HEAD  OF  TRICEPS. 
TERES   MAJOR. 
aORSALIS  SCAPULAE    A. 
LONG  SUBSCAPULAR   N. 
SUBSCAPULAR   A. 
-SUBSCAPULARIS  M. 
MIDDLE  SUBSCAPULAR  N. 

Fig.  219. — Ligature  of  axillary  and  brachial  arteries.     Exposure  of  the  profunda  artery 
and  the  various  nerves  associated  with  these  vessels. 


182 


OPERATIVE  SURGERY. 


don.    The  brachial  artery  may  he  ligatured  at  three  situations — at  its  upper, 
middle,  and  lower  thirds. 

The  Operation^  Upper  Third. — Abduct  the  arm  and  rotate  it  outward. 
Make  an  incision  about  three  inches  in  length  along  the  inner  border  of 


Pig.  220. — TransA'erse  section  of  right  arm  at  axilla. 

A.  Cephalic  vein.  B.  Pectoralis  major.  C.  Biceps  tendon.  D.  Musculo-cutaneous  nerve. 
E.  Internal  cutaneous  nerve.  F.  Median  nerve.  G.  Basilic  vein.  H.  Brachial 
artery.    /.  Ulnar  nerve.     J.  Brachial  vein.     K.  Musculo-spiral  nerve. 


the  coraco-brachialis  muscle.  The  artery,  being  very  superficial,  is  quickly 
reached  (Fig.  320).  The  median  nerve  is  drawn  to  the  outer  side,  and  the 
ulnar  nerve  and  basilic  vein  to  the  inner  side ;  separate  the  artery  from  the 
vein,  and  pass  the  needle  from  within  outward. 

The  Operation,  Middle  Third. — Place  the  arm  as  before.  Make  an  in- 
cision three  inches  in  length  along  the  inner  side  of  the  biceps  muscle  ( Fig. 
319,  a).  The  median  nerve  is  found  lying  upon  and  a  little  to  the  inner  side 
of  the  vessel  (Fig.  221).  Push  it  aside,  isolate  the  artery  from  the  venae 
comites,  and  pass  the  needle  in  the  same  direction  as  before. 

The  Operation,  Lower  Third  (Fig.  222,  f) . — Abduct  the  arm  and  supinate 
the  forearm."  Compress  the  arm  above  to  distend  the  median  basilic  vein. 
Make  an  incision  about  three  inches  in  length  along  the  inner  border  of  the 
tendon  of  the  biceps;  draw  aside  the  median  basilic  vein,  and  the  artery 
will  be  felt  pulsating  beneath  the  bicipital  fascia.    A  suitable-sized  opening 


THE   LIGATURE   OF  ARTERIES. 


183 


is  now  cut  through  this  fascia  (Fig.  223^  E),  the  forearm  i)artially  flexed,  the 
vessel  separated  from  its  veins,  and  the  needle  passed  from  within  outward. 
The  importance  of  the  bicipital  fascia  in  connection  with  flexion  and  pro- 
nation of  tlie  forearm  should  limit  as  much  as  possible  any  destructive  inter- 
ference with  it. 

The  Fallacies. — The  arteries  of  the  forearm  may  come  from  the  axil- 
lary, or  the  brachial  may  bifurcate  high  up,  thereby  increasing  the  number 
of  the  large  vessels  in  the  arm.  This  fact  is  determined  by  the  compara- 
tive size  of  the  brachial,  and  the  influence  of  pressure  on  its  circulation  at 
the  distal  side  of  the  proposed  ligature.  The  brachial  artery  may  run  behind 
the  inner  condyle  along  with  the  ulnar  nerve.  If  the  artery  be  not  in  its 
normal  site,  deep  pressure  on  the  arm  may  detect  arterial  pulsation  else- 
Avhere,  which,  together  with  the  effect  of  the  pressure  on  the  circulation  be- 
yond, will  determine  the  size  and  site  of  the  vessel.  Each  of  the  pro- 
funda branches  has  been  mistaken  for  the  main  vessel.  The  incision  at  the 
upper  two  thirds  may  be  made  too  far  inward,  causing  the  surgeon  to  mis- 
take the  ulnar  for  the  median  nerve.     If  the  forearm  be  flexed  and  gentle 


Fig.  221. — Transverse  section  of  right  arm  at  the  middle  third. 

A.  Superior  profunda  artery  and  veins.  B.  Musculo-spiral  nerve.  C.  Cephalic  vein. 
D.  Musculo-cutaneous  nerve.  E.  Brachial  artery  and  veins.  F.  Median  nerve. 
O.  Internal  cutaneous  nerve.     H.  Basilic  vein.     /.  Ulnar  nerve. 


upward  traction  be  made  upon  either,  the  course  of  the  nerve  will  be  deter- 
mined, and  the  danger  of  this  will  be  easily  avoided. 

The  median  nerve  may  pass  behind  the  artery  instead  of  in  front  of  it; 
then,  if  the  circulation  from  above  be  obstructed,  the  artery  may  escape 


184 


OPEEATIVE  SURGERY. 


BRACHIALIS  ANIICUS  M. 

MUSCULO-CUTANEOUS  N. 

SUPINATOR  LONGUS  M. 

TENDON  OF  BICEPS. 


BADIAL  A.Wmi  VENfE  COMITES. 
RADIAL  N. 
SUPINATOR  LONGUS  M. 
PRONATOR  RADII    TERES  M. 
FLEXOR  CARPI  RADIAL  IS  M. 


BADIAL  A.  WITH  VEH/E  COMITES 
RADIAL  N. 
FLEXOR  LONGUS  POLUCIS 
SUPINATOR  LONGUS  M. 
TENDDNQP  FLEXORCARPI  RADIALIS 

RADIAL  /l..„,[jp;:p 

TENDON  OF  FLEXOR  CARPI  fl/lDML/sJjN 

EXTEN.OSSISAND  PRIMI  l 
INTERNOQll  POLUCIS.   ) 

SUPERFIDIAUS  VOUE  A 


BBADHIALA&VEMCBMITES. 
MEDIAN  N. 
BJCIPITAL  FASCIA. 
MEDIAN  BASILIC   V. 
INT.  CUTAN.   N. 


FLEXOR.SUBLIMJS.DIGIT  M. 

PLEXOR  CARPI  ULNARIS  M. 
^FLEXOR  PROFUNDUS  DIGIT  M. 
ULNAR  A. 
ULNAR  N 


FLEXOR  SUBLIMIS  DIGIT.  M. 
FLEXOR  CARPI  ULNARIS  M. 


ULNAR  N. 
ULNAR  A. 

ANT.  ANNULAR  LIE. 
TENDON  OF  FLEX.GARP.ULMARIS. 
PISIFORM   BONE. 
PALMARIS  BREVIS  M, 


Fig.  222. — Ligature  of  radial  and  ulnar  arteries. 
a,  I,  c.  Ligature  of  radial  and  ulnar  at  upper  (a),  middle  (J),  and  lower  (c)  thirds  respec- 
tively.   /.  Ligature  lower  third  brachial  artery. 


THE   LIGATURE   OF   ARTERIES. 


185 


notice.     The  artery  not  infrequently  lies  deeply  between  the  brachialis  an- 
ticus  and  biceps  muscles. 

Anomalous  muscular  slips  and  unusual  muscular  development  may  ob- 
scure the  artery  in  its 
normal  course.  In 
such  instances  the  pul- 
sation will  determine 
the  location. 

Occasionally,  espe- 
cially in  female  sub- 
jects, when  the  upper 
extremity  is  markedly 
concave  on  its  outer 
surface,  due  to  an  uu- 
usual  length  of  the  in- 
ternal condyle,  the  pri- 
mary incision  may  be 
made  unintentionally 
to  the  outer  side  of  the 
vessel.  If,  however,  it 
be  made  midway  be- 
tween thea pices  of  the 
hony  condyles,  this 
error  will  not  arise. 

The  Results.— Oi 
211  cases  of  ligature, 
54  died;  of  189  before  asepsis,  for  hemorrhage  and  traumatic  aneurism,  54 
died;  of  22  under  it:  15  for  haemorrhage  and  7  for  aneurism,  all  recovered. 

Ligature  of  the  Radial  Artery. — The  radial  artery  on  account  of  the 
exposed  position  is  frequently  injured. 

The  Anato?nical  Points. — It  arises  from  the  brachial,  is  an  apparent 
continuation  of  it,  and  is  superficial  in  its  entire  route. 

The  Contiguous  Anatomy. 

The  Relations  of  the  Radial  Artery.    (Gray.) 
In  front. 
Integument — superficial  and  deep  fasciae. 
Supinator  longus. 
Inner  side. 


Fig.  223. — Transverse  section  through  the  right  elbow  joint. 

A.  Radial  nerve.  B.  Cephalic  vein.  C.  External  cuta- 
neous nerve.  D.  Median  vein.  U.  Brachial  artery  and 
veins.  F.  Basilic  vein.  G.  Internal  cutaneous  nerve. 
H.  Median  nerve.    J,  J.  Ulnar  nerve.    K.  Ulnar  vein. 


Pronator  radii  teres. 
Plexor  carpi  radialis. 


Radial  artery  ) 
in  forearm.     ) 


Outer  side. 
Supinator  longus. 
Radial  nerve  (middle  third). 


Behind. 
Tendon  of  biceps. 
Supinator  brevis. 
Pronator  radii  teres. 
Flexor  snblimis  digitorum. 
Flexor  longus  pollicis. 
Pronator  quadratus. 
Radius. 


186 


OPERATIVE  SURGERY. 


Tlie  linear  guide  (Fig.  222)  to  this  vessel  is  drawn  midway  (dotted  line) 
between  the  apices  of  the  bony  condyles  of  the  humerus  to  the  inner  side 
of  tjie  extremity  of  the  styloid  process  of  the  radius. 

Tlie  muscular  guide,  at  the  upper  portion,  is  the  inner  border  of  the 
belly  of  the  supinator  longus  muscle,  beneath  which  the  vessel  usually  lies. 
At  the  lower  portion  of  the  course  it  lies  at  the  inner  side  of  the  tendon 
of  the  same  muscle.  The  pulsation  of  the  vessel  at  the  wrist  is  the  best 
practical  guide  to  it  in  this  location.  In  fact,  it  is  only  when  abnormali- 
ties in  size  or  situation  occur  at  this  position  that  the  other  guides  are 
taken  into  serious  consideration  in  the  living  subject,  and  under  these  cir- 
cumstances they  are  of  but  little  aid  to  the  operator.  This  same  statement 
will' apply  with  equal  force  to  all  arteries  that  are  similarly  associated  with 
the  superficial  structures  of  the  body. 

While  the  artery  may  be  ligatured  in  any  portion  of  its  course,  it  is,  how- 
ever, usually  ligatured  at  three  situations — at  the  upper  and  lower  thirds, 
and  at  the  apex  of  the  styloid  process. 

The  Operation,  Upper  Third  (Fig.  222,  a). — Supinate  the  forearm  ;  press 
upon  the  arm  above  the  seat  of  operation  to  distend  the  superficial  veins; 
make  an  incision  about  three  inches  in  length  along  the  linear  guide  to  the 
vessel.     After  going  through  the  fascise,  the  inner  edge  of  the  supinator 


Fig.  224. — Transverse  section  of  right  forearm  at  upper  third. 

A.  Posterior  interosseous  nerve.  B,  F.  Radial  veins.  G.  Anterior  interosseous  vessels. 
D.  Radial  nerve.  E.  Radial  artery  and  veins.  G.  Ulnar  vein.  H.  Median  nerve. 
/.  Ulnar  nerve.     J.  Ulnar  arterv  and  veins. 


longus  will  be  found  extending  beyond  the  line  and  overlapping  the  artery ; 
separate  and  pull  this  muscle  outward,  when  the  artery  will  be  seen  lying 


THE  LIGATURE   OP  ARTERIES. 


187 


between  its  veins,  with  the  nerve  to  the  radial  side  (Figs.  224  and  225) ; 
isolate  the  artery,  and  pass  the  needle  from  without  inward. 


Fig.  225. — Transverse  section  of  right  forearm  at  middle  third. 

A,  Anterior  interosseous  artery,  veins,  and  nerve.  B.  Tendon  of  extensor  carpi  radialis 
longior.  C.  Radial  nerve.  Z>.  Pronator  radii  teres.  E.  Radial  artery  and  attend- 
ing veins.  F,  G.  Superficial  radial  veins.  H.  Median  nerve.  I.  Palmaris  longus. 
J.  Ulnar  artery,  veins,  and  nerve.  K.  Superficial  ulnar  vein.  L.  Extensor  longus 
pollicis. 

The  Operation,  Lower  Third,  Ujjper  and  Lower  Limits  (Fig.  222,  J,  c). — 
At  these  situations  the  vessel  is  very  superficial,  its  well-known  pulsation  be- 
ing the  best  guide  to  it.  With  the  arm  placed  as  in  the  preceding  position, 
make  an  incision,  in  either  instance,  two  inches  in  length  along  the  course 
of  the  vessel.  After  the  division  of  the  integument  and  fasciae  the  artery 
will  be  seen  surrounded  by  loose  areolar  tissue,  accompanied  by  its  veins,  and 
lying  to  the  inner  side  of  the  tendon  of  the  supinator  longus.  Separate  the 
tissues  and  ligature  the  artery,  passing  the  needle  from  the  nerve. 

The  Operation  at  Apex  of  Styloid  Process  (Fig.  226). — At  this  situation 
the  vessel  is  found  in  a  triangular-shaped  space,  bounded  internally  by  the 
tendon  of  the  extensor  primi  internodii  pollicis,  externally  by  that  of  the 
extensor  secundi  internodii  pollicis,  and  the  base  corresponding  to  the  apex 
of  the  styloid  process  of  the  radius.  If  the  thumb  be  forcibly  extended,  the 
outlines  of  the  space  will  be  well  marked. 

The  Operation. — Place  the  hand  midway  between  supination  and  pro- 
nation, and,  having  ascertained  the  exact  situation  of  the  tendon  of  the  ex- 
tensor primi  internodii  pollicis,  make  an  incision  near  to  its  outer  border 
about  an  inch  in  length  ;  use  care  not  to  divide  the  superficial  veins.  The 
areolar  tissue  and  the  extensor  primi  internodii  pollicis  are  pulled  aside,  and 
the  vessel  found  somewhat  deeply  situated.  The  needle  can  be  carried  in 
either  direction. 


188 


OPERATIVE  SURGERY. 


The  Fallacies. — The  radial  artery  may  lie  upon  the  fascia  and  supinator 
longus  instead  of  beneath  them ;  it  may  pass  over  the  extensor  tendons  of 

the    thumb    instead    of    beneath 

liTEmON  OF  EnEflSOR 
m:ARPl  RADIAUS  LONGIOR 

.RADIAL  N 
liTENDONOFEXTDISOR 
({SECUNDI  mERNOail  POLLICIS 
/EKTEN  PRIM  INTER.  POLL 

.RADIAL  A 


VEN/E  COMITl    ' 


VEN/Z  COMIl 


(tendon  OF EXTEN 
[CARP  RAD  LONG 
RADIAL   A 

PJDDRSAL  INTER- 
OSSEOUS M 


them.  The  artery  may  be  mis- 
taken for  a  radicle  of  the  radial 
vein.  The  latter  is  superficial, 
and  has  likewise  other  character- 
istics of  a  vein.  In  ligaturing  the 
vessel  at  either  of  the  last  two 
positions  sheaths  of  contiguous 
tendons  will  be  opened  if  incau- 
tious vigor  be  exercised. 

The  Results. — During  the  late 
civil  war  the  radial  artery  was 
tied  twenty  times,  with  four  fatal 
results. 

Ligature  of  tlie  Ulnar  Artery. 
— The  ulnar  artery  is  less  fre- 
quently injured  than  the  radial, 
and  requires  therefore  less  opera- 
tive interference  than  the  latter. 

The  Anatomical  Points. — The 
ulnar  artery  is  larger  than  the  ra- 
dial. It  is  given  off  from  the 
brachial  about  one  inch  below  the 
bend  of  the  elbow,  passes  oblique- 
ly inward  and  downward  deeply 
beneath  the  superficial  flexors  of  the  forearm,  and  gains  the  ulnar  side  of  the 
forearm  a  little  above  its  middle ;  becoming  more  superficial,  passes  along 
the  radial  side  of  the  flexor  carpi  ulnaris  to  the  radial  side  of  the  pisiform 
bone,  where  it  terminates  in  the  superficial  palmar  arch. 
The  Contiguous  Anatomy. 

The  Relations  of  the  Ulnar  Artery.    (Gray.) 

In  front. 
Superficial  layer  of  flexor  muscles. 
Median  nerve. 
Superficial  and  deep  fasciae. 
Inner  side. 
Flexor  carpi  ulnaris.  j  Ulnar  artery  ) 

Ulnar  nerve  (lower  two  thirds)-  ]    in  forearm.    \ 

Behind. 
Brachialis  anticus. 
Flexor  profundus  digitorum. 

The  linear  guide  to  the  lower  two  thirds  of  the  vessel  is  drawn  from  the 
apex  of  the  internal  condyle  (Fig.  322  *)  to  the  radial  side  of  the  pisiform 
bone. 

The  muscular  guide  is  the  radial  border  of  the  flexor  carpi  ulnaris. 


Fig.  226. — Ligature  of  radial  at  apex  of  styloid 
process. 


C  Upper  half. 

Lower  half. 

Outer  side. 
Flexor  sublimis  digitorum. 


THE   LIGATURE  OF  ARTERIES.  189 

The  vessel  may  he  ligatured  at  three  situations:  1,  At  the  junction  of  the 
upper  and  middle  thirds ;  2,  at  the  lower  third ;  3,  at  the  wrist.  It  can  be 
ligatured  at  its  upper  third,  but  such  a  step  has  no  practical  utility  except 
when  required  on  account  of  a  direct  injury  of  this  portion  of  the  vessel ;  it 
is  then  tied  at  the  seat  of  injury. 

The  Operation,  Junction  of  Middle  and  Upper  Thirds  (Fig.  222,  a). — 
Supinate  the  forearm,  and  make  an  incision  on  the  linear  guide  to  the  vessel, 
beginning  at  about  four  finger  breadths  below  the  internal  condyle  of  the 
humerus,  about  three  inches  in  length.  Divide  the  fascia  on  a  director; 
seek  for  a  line  of  connection  between  the  borders  of  the  flexor  carpi  ulnaris 
and  the  flexor  sublimis  digitorum.  It  is  of  a  yellowish-white  color.  Divide 
it  in  the  long  axis  and  pull  the  muscles  apart,  when  the  ulnar  nerve  will 
be  seen,  to  the  outer  side  of  which  will  be  found  the  artery  with  its  accom- 
panying veins;  separate  the  artery  and  pass  the  needle  from  within  out- 
ward. 

The  Operation  in  the  Lower  Third  (Fig.  222,  &). — Place  the  forearm  as 
in  the  preceding  operation;  extend  the  hand  to. make  the  tendon  of  the 
flexor  carpi  ulnaris  tense;  make  an  incision  about  three  inches  in  length 
along  the  radial  border  of  this  muscle  down  to  the  fascia.  Divide  the  fascia, 
exposing  the  tendon  of  the  flexor  carpi  ulnaris,  which  is  drawn  inward,  and 
the  artery  is  seen  beneath  it.  Isolate  the  vessel  from  its  veins  and  pass  the 
needle  from  within  outward. 

The  Operation  at  the  AYrist  (Fig.  222,  c). — Place  the  hand  on  its  dorsal 
surface,  and  make  an  incision  about  two  inches  in  length  along  the  radial 
side  of  the  pisiform  bone,  with  its  convexity  outward ;  carry  it  downward 
along  the  side  of  that  bone  through  the  fascia  and  fatty  tissue  to  the  vessel. 
Flex  the  hand  and  pass  the  ligature  from  within  outward. 

The  Fallacies. — For  an  operation  without  special  gravity  the  ligaturing 
of  the  vessel  at  the  upper  portion  is  attended  with  confusing  circumstances 
that  often  defeat  the  object  of  the  surgeon.  Between  the  upper  and  middle 
thirds,  the  interspace  between  the  flexor  carpi  ulnaris  and  flexor  sublimis 
digitorum  muscles  may  be  mistaken  for  that  between  the  flexor  carpi  ulnaris 
and  the  palmaris  longus  muscles,  or  the  one  between  the  palmaris  longus 
and  flexor  carpi  radialis.  The  "  white "  or  "  yellowish-white  "  interspace 
between  the  proper  muscles  may  be  indistinct,  and  even  absent.  It  is  best 
marked  in  muscular  subjects ;  least  observable  and  most  frequently  absent 
in  aged  and  emaciated  persons.  The  upper  extremity  of  the  linear  guide 
should  begin  at  the  ajjex  of  the  internal  condyle.  If  the  carpus  and  fingers 
be  moved  independently  of  each  other  after  the  division  of  the  integument 
and  fasciae,  the  septum  between  the  flexor  carpi  ulnaris  and  the  flexor  sub- 
limis digitorum  muscles  can  be  easily  ascertained. 

In  the  upper  third  the  vessel  runs  downward  and  inward  to  the  ulnar 
side  of  the  forearm  to  meet  the  linear  guide  of  the  lower  two  thirds  ;  there- 
fore an  attempt  to  find  the  artery  by  the  linear  guide,  in  the  upper  third, 
will  be  futile.  The  artery  may  run  beneath  the  fascia,  or  otherwise  vary  in 
its  direction  ;  if  it  be  not  in  the  normal  situation,  deep  pressure  may  locate 
its  presence  and  define  its  course. 


190 


OPERATIVE   SURGERY. 


The  Results. — The  ulnar  artery  was  ligatured  during  the  late  war  ten 
times,  with  three  deaths. 

Ligature  of  the  Palmar  Arches. — The  superficial  and  deep  palmar  arches 
are  liable  to  injury  from  traumatic  violence,  and  it  is  from  this  cause  that 
ligature  of  them  is  principally  demanded.  The  free  communication  of  the 
arches  with  other  arteries  through  their  numerous  branches  greatly  exposes 
the  patient  to  the  danger  of  secondary  hsemorrhage. 
The  Contiguous  Anatomy. 

The  Relations  of  the  Superficial  Arch.     (Gray.) 

In  front. 

Integument.     ' 

Palmaris  brevis. 

Palmar  fascia. 

Superficial  palmar  arch. 

Behind. 
Annular  ligament. 
Origin  of  muscles  of  little  finger. 
Superficial  flexor  tendons. 
Division  of  the  median  and  ulnar  nerves. 

The  Linear  Guide. — The  linear  guide  to  the  superficial  arch  is  a  line  ex- 
tending across  the  palm  di- 
rectly along  the  palmar  bor- 
der of  the  thumb  when  ab- 
ducted to  a  right  angle  with 
the  index  finger  (Fig.  227). 
This  line  indicates  the  low- 
er limit  of  the  arch.  The 
deep  arch  is  from  half  to 
three  quarters  of  an  inch 
nearer  the  wrist  joint  than 
the  superficial  one. 

The  Operation.  —  Make 
an  incision  an  inch  in  length 
at  the  seat  of  the  injury, 
parallel  with  the  nerves  and 
tendons  of  the  palm,  through 
the  superimposed  tissue  down 
to  the  vessel.  Ligature  all 
bleeding  points,  and  also  all 
uninjured  branches  arising 
close  to  the  seat  of  the  in- 
jury of  the  main  vessel,  to 
avoid  the  possibility  of  sec- 
ondary haemorrhage.  The 
deep  palmar  arch  is  treated 
in  a  similar  manner.  However,  a  greater  degree  of  caution  is  necessary,  for 
the  vessel  is  more  intricately  and  deeply  placed  than  is  the  former. 


SUPEPFICIALIS  VOL/E 


INTEROSSEOUS  J- \^ 
12.3.4.  DI6ITA 


Pig.  237.  — The  palmar  arches. 


THE   LIGATURE   OP  ARTERIES.  191 

Irresioective  of  the  seat  of  the  injury  the  superficial  palmar  arch  can  be 
exposed  tlirough  an  incision  extending  from  the  junction  of  the  thenar  emi- 
nences toward  the  ring  finger.  The  deep  palmar  arch  can  be  tied  opposite 
the  middle  of  the  base  of  the  thumb  through  an  incision  beginning  at  the 
junction  of  the  thenar  eminences  and  extending  along  the  crease  of  the 
opponeus  pollicis  toward  the  little  finger. 

The  Precautions. — All  incisions  should  be  carefully  made  in  the  long  axis 
of  the  palm,  to  avoid  as  far  as  possible  injury  of  subjacent  nerves,  tendons, 
and  arteries.  Branches  arising  immediately  adjacent  to  the  seat  of  ligature 
should  be  tied,  to  afford  room  for  the  establishment  of  proper  blood  clots  in 
the  ligatured  vessel.  If  the  vessel  be  injured,  it  should  be  tied  at  either  side 
of  the  seat  of  injury. 

Ligature  of  the  Commoii  Carotid  Artery. — The  common  carotid  artery 
is  the  most  important  vessel  in  the  neck,  and  frequently  demands  operative 
procedure. 

The  Anatomical  Points. — The  right  common  carotid  arises  from  the  in- 
nominate artery,  and  the  left  from  the  arch  of  the  aorta.  The  left  is  con- 
sequently longer  and  more  deeply  situated  in  the  chest.  The  left,  after 
leaving  the  aorta,  passes  obliquely  upward  to  a  point  opposite  the  left  sterno- 
clavicular articulation ;  and  from  this  point  onward  the  right  and  left  com- 
mon carotids  maintain  substantially  the  same  course  to  the  upper  border  of 
the  thyroid  cartilage,  where  each  divides  into  the  internal  and  external 
carotids. 

The  Contiguous  Anatomy. 

The  Relations  of  the  Common  Carotid  Artery.     (Gray.) 

In  front. 
Integument  and  fascia.  Omo-hyoid. 

Platysma.  Descendens  noni  nerve. 

Sterno-mastoid.  Sterno-mastoid  artery. 

Sterno-hyoid.  Superior  thyroid,  lingual,  and  facial  veins. 

Sterno-thyroid.  Anterior  jugular  vein. 

Externally.  Internally. 

Trachea. 
(  Common  )      Thyroid  gland. 
Internal  jugular  vein.     )    ^^^^^.^    {      Recurrent  laryngeal  nerve. 
Pneumogastric  nerve.      (    ^^^^^^    )      Inferior  thyroid  artery. 

Larynx. 
Pharynx. 

•  Behind. 

Longus  colli.  Sympathetic  nerve. 

Rectus  capitis  anticus  major.  Inferior  thyroid  artery. 

Recurrent  laryngeal  nerve. 

The  linear  guide  to  the  vessel  is  a  line  drawn  from  the  sterno-clavicular 
articulation  to  midway  between  the  angle  of  the  jaw  and  mastoid  process. 

The  muscular  guide  to  the  operatio7i  is  the  anterior  border  of  the  sterno- 
cleido-mastoid  muscle.. 


192 


OPERATIVE  SURGERY. 


Each  vessel  may  be  ligatured  at  three  situations:  1,  At  the  root  of  the 
neck;  2,  just  below  the  omo-hyoid  muscle;  3,  above  that  muscle.  The  last 
two  are  the  situations  commonly  selected^  the  first  not  being  employed 
except  under  forced  circumstances. 

The  Operation  helow  the  Omo-hyoid  (Fig.  228,  1). — Place  the  patient 
on  the  back,  with  the  shoulders  slightly  elevated,  and  the  head  turned  to  the 
opposite  side;  make  an  incision  three  inches  in  length,  beginning  a  little 
above  the  level  of  the  cricoid  cartilage,  on  the  line  stated,  and  carry  it  down- 


OMO-HYOID    M  . 

JUGULAR     V. 

JCOMMUNICANS. 
\  HYPO- GLOSS  I  N. 

^^^EXT.CAROTID  A. iZ). 

EXT.  CAROTID    A  .{}). 


STERNO-THYOID    M. 


STERNO-HYOID. 
Pig.  228. — Ligature  of  coinmon  carotid  artery. 
1.  Ligature  below  omo-hyoid.     2.  Ligature  above  omo-hyoid  muscle. 

ward  along  the  anterior  border  of  the  sterno-mastoid  (Fig.  205,  c)  ;  divide 
the  superficial  fascia,  platysma,  and  deep  fascia  on  a  director,  thus  expos- 
ing the  anterior  border  of  the  sterno-mastoid  muscle.  If  the  sterno-mastoid 
artery  be  divided,  ligature  it.  If  not  injured,  push  it  aside,  together  with 
the  thyroid  vein;  draw  the  sterno-mastoid  muscle  outward  and  the  sterno- 
thyroid and  hyoid  muscles  inward,  then  the  lower  border  of  the  omo-hyoid 
will  be  seen  above;  divide  the  fascia  beneath  these  muscles  and  draw  the 
borders  apart,  when  the  descendens  noni  nerve  will  be  seen  resting  upon 
the  inner  portion  of  the  common  sheath  of  the  carotid  artery,  internal 
jugular  vein,  and  the  pneumogastric  nerve,  the  artery  being  to  the  inner 
side,  the  pneumogastric  nerve  behind  and  between  the  two  and  out  of  sight. 
Place  the  finger  upon  the  sheath,  to  ascertain  the  exact  location  of  the  artery ; 
raise  the  portion  of  the  sheath  corresponding  to  the  site  of  the  artery  at  the 
inner  side  with  a  tenaculum  or  the  thumb  forceps,  cut  a  small  opening  into 
it,  grasp  and  hold  apart  the  borders  with  thumb  forceps,  and  pass  the  needle 
from  without  inward,  cautiously  insinuating  it  between  the  vessel  and  the 
sheath  (Fig.  228, 1) .  The  manipulation  should  be  carefully  done,  else  either 
the  vein,  pneumogastric,  or  recurrent  laryngeal  nerves  may  be  injured. 
The  Operation  ahove  the  Omo-hyoid  (Fig.  228,  2). — The  vessel  is  more 


THE    LIGATURE    OF   ARTERIES.  193 

superficial  here  than  below  the  omo-hyoitl,  and  this  situation  is  therefore 
denominated  "  the  site  of  election." 

Place  the  patient  as  before,  and  make  an  incision  along  the  anterior 
border  of  the  sterno-mastoid,  beginning  at  about  the  angle  of  the  lower 
jaw,  and  extending  it  to  a  little  below  the  cricoid  cartilage ;  divide  the  super- 
ficial fascia,  plat3'sraa,  and  deep  fascia  on  a  director,  carefully  avoiding  the 
small  veins ;  expose  the  anterior  border  of  the  sterno-mastoid,  and  slightly  flex 
the  head  to  relax  the  tissues  of  the  neck  ;  draw  the  edges  of  the  wound  apart, 
and  the  artery  will  be  felt  pulsating  in  its  sheath.  If  the  jugular  vein  over- 
lap it,  the  vein  should  be  emptied  by  pressure  made  above  and  below,  and  be 
drawn  outward  ;  then  carefully  open  the  sheath  as  before,  avoiding  the  de- 
scendens  hypoglossi  nerve  ;  pass  the  needle  cautiously  from  without  inward. 
It  is  well  to  observe  the  upper  border  of  the  omo-hyoid  muscle  before  opening 
the  sheath,  so  that  the  exact  location  to  apply  the  ligatui'S  may  be  assured. 

The  Fallacies. — The  artery  may  bifurcate  at  the  cricoid  cartilage,  and 
even  lower ;  however,  this  bifurcation  is  extremely  rare ;  under  such  cir- 
cumstances both  branches  should  be  secured.  If  the  vessel  be  pressed  upon 
before  the  ligature  is  tied,  the  pressure  will  determine  the  influence  of  the 
ligaturing  upon  the  branches  above,  and  thus  obviate  an  error  of  application. 

The  jugular  vein  may  be  much  dilated,  overlie  and  receive  the  impulse 
of  the  artery,  and  therefore  be  mistaken  for  it.  This  fallacy  will  be  avoided 
if  the  vein  be  emptied  of  its  blood  in  the  manner  before  described.  The 
thyroid  body  may  be  enlarged  and  obscure  the  artery  by  displacing  or  over- 
lapping it.  Under  these  conditions  it  should  be  pushed  aside.  It  is  re- 
ported that  the  omo-hyoid  muscle  has  been  mistaken  for  the  artery ;  the 
fact  of  its  being  muscular,  taken  in  connection  with  the  direction  of  the 
fibers,  together  with  its  anatomical  relations,  should  eliminate  any  liability 
of  this  mistake.  A  large  branch  arising  from  the  main  trunk  may  be  mis- 
taken for  the  external  carotid.  However,  the  comparative  size  of  the  vessel 
and  the  influence  of  pressure  on  the  circulation  of  the  branch  will  effectually 
solve  the  question.  If  branches  be  given  off  from  the  common  carotid  near 
the  site  of  the  proposed  ligaturing,  they  should  be  tied  also. 

A  broad  sterno-mastoid  may  cause  confusion  by  the  placing  of  the  inci- 
sig-u  too  far  inward  ;  if  narrow,  or  the  head  be  turned  far  outward,  the  mus- 
cle may  again  misdirect  the  incision,  this  time  to  the  outer  side  of  the 
vessel.  Respiratory  movements  of  the  tissues  of  the  neck,  inflammatory 
processes,  morbid  growths,  and  dilated  veins,  each  contribute  more  or  less 
to  the  difficulties  of  the  occasion.  It  should  not  be  overlooked  that  liga- 
ture of  the  common  carotid  for  haemorrhage  from  either  the  internal  or 
external  divisions  will  not  likely  be  effective,  on  account  of  the  free  commu- 
nication of  these  two  vessels  at  the  point  of  bifurcation  of  the  main  trunk, 
to  say  nothing  of  the  collateral  flow  from  the  opposite  side. 

The  Results. — Of  83-1  cases  of  ligature,  327  died;  of  789  before  asepsis, 
323  died;  of  45  under  asepsis,  4  died;  i.  e.,  19  for  aneurism,  11  died;  23  for 
haemorrhage,  3  died ;  3  for  tumor,  no  death. 

Ligature  of  Both  Commoii  Carotids. — Ligature  of  both  common  carot- 
ids, either  simultaneously  or  at  variable  intervals,  has  been  done  thirty-six 


194  OPERATIVE  SURGERY. 

times.  The  shortest  interval  between  operations  in  which  recovery  has 
taken  place  is  four  and  a  half  days.  Instances  where  the  interval  varied 
from  thirteen  to  thirty  days  are  reported,  with  recovery  of  the  patients. 

Temporary  Ligature  of  the  Common  Carotid. — The  carotid  may  be  tem- 
porarily ligatured.  The  procedure  has  been  resorted  to  by  Eivington  and 
others,  with  the  view  of  arresting  haemorrhage  arising  from  branches  of  the 
common  carotid  without  exposing  the  patient  to  the  dangers  of  brain  com- 
plications incident  to  permanent  closure.  The  operation  consists  in  expos- 
ing the  vessel  in  the  usual  manner  and  passing  around  it  a  broad  catgut  or 
other  ligature,  which  is  tightened  or  raised  sufficiently  to  close  the  lumen  of 
the  vessel  and  arrest  haemorrhage.  If  in  troublesome  bleeding  during 
operation  a  ligature  is  passed  around  the  vessel  that  supplies  blood  to  the 
operative  field,  and  raised  from  time  to  time  sufficiently  to  control  the 
blood  current,  finally  being  removed,  much  blood  will  be  spared  and 
valuable  time  gained.  The  external  carotid  is  treated  similarly  for  like 
reasons  with  equally  good  effects. 

Ligature  of  the  External  Carotid  Artery. — The  external  carotid  artery 
is  tied  at  one  or  both  sides  to  prevent  the  free  loss  of  blood  that  so  often 
attends  operations  within  the  field  of  its  supply.  The  fear  of  secondary 
haemorrhage  can  not  be  urged  in  opposition  to  the  measure  if  the  collateral 
branches  near  to  the  seat  of  the  ligature  be  tied  at  the  same  time.  The 
author  has  practiced  this  plan  repeatedly,  and  with  eminent  success  in 
each  instance  but  one.  In  this  one  the  facial  arose  from  the  common  carot- 
id, Just  below  the  bifurcation,  and  the  patient  died  from  secondary  haemor- 
rhage, caused  by  sloughing  of  a  malignant  growth  in  which  the  facial  was 
involved,  and  for  the  amelioration  of  which  both  external  carotids  had 
been  tied  simultaneously.    Dawbarn  removes  the  vessels  (page  209).  , 

The  Anatomical  Poifits. — The  external  carotid  artery  arises  from  the 
common  carotid  at  or  just  above  the  upper  border  of  the  thyroid  cartilage. 
It  ascends  in  a  slightly  curved  course,  with  the  convexity  forward,  to  a  point 
midway  between  the  neck  of  the  condyle  of  the  lower  jaw  and  the  external 
auditory  meatus.  The  upper  part  of  its  course  lies  in  the  substance  of  the 
parotid  gland. 

The  Contiguous  Anatomy. 

The  Relations  of  the  External  Carotid.    (Gray.) 
In  front.  Behind. 

Integument,  superficial  fascia.  Superior  laryngeal  nerve. 

Platysma  and  deep  fascia.  C  External  ^  Stylo-glossus. 

Hypoglossal  nerve.  <    carotid    >         Stylo-pharyngeus. 

Lingual  and  facial  veins.  '    artery,    f         Glosso-pharyngeal  nerve. 

Digastric  and  stylo-hyoid  muscles.  Internal  carotid  artery. 

Parotid  gland,  with  facial  nerve  and  Parotid  gland, 

temporo-maxillary  vein  in  its  sub- 
stance. 

Internally. 
Hyoid  bone. 
Pharynx. 
,  Parotid  gland. 

Ramus  of  jaw. 


THE  LIGATURE  OP   ARTERIES.  I95 

The  linear  and  muscular  guides  are  substantially  the  same  as  those  of  the 
common  carotid. 

The  bony  guide  is  the  greater  cornu  of  the  hyoid  bone,  which  lies  to  the 
inner  side  of  the  vessel,  above  the  bifurcation  of  the  common  carotid  and 
near  to  the  origin  of  the  lingual  artery.  If  pressure  be  made  on  one  side  of 
the  hyoid  bone  the  greater  cornu  will  be  made  prominent  on  the  opposite 
side  and  easy  of  determination. 

The  artery  7nay  he  tied  at  two  situations :  above  and  below  the  posterior 
belly  of  the  digastric  muscle.  The  latter  situation  is  the  one  to  be  selected, 
if  possible. 

The  Operation  below  the  Digastric  Muscle. — With  the  patient  on  the 
back,  head  slightly  extended  and  turned  to  the  opposite  side,  make  an  in- 
cision along  the  anterior  border  of  the  sterno-mastoid,  beginning  opposite 
the  angle  of  the  lower  jaw,  and  carry  it  downward  to  a  point  nearly  opposite 
the  cricoid  cartilage  (Fig.  214,  b).  Divide  the  superficial  fascia,  platysma, 
and  deep  fascia,  and  expose  the  anterior  border  of  the  sterno-mastoid.  The 
edges  of  the  wound  should  be  drawn  well  apart,  when  the  hypoglossal  nerve 
and  the  digastric  and  stylo-hyoid  muscles  will  come  into  view  (Fig.  216). 

The  end  of  a  grooved  director  should  now  be  employed  to  separate  and 
push  aside  the  lingual  and  facial  veins,  together  with  the  areolar  tissue  and 
lymphatic  glands  that  rest  upon  the  vessel.  Expose  the  artery  and  pass  the 
ligature  from  without  inward.  The  internal  jugular  vein  ofttimes  overlaps 
the  vessel,  and  should  be  carefully  drawn  aside,  or  treated  as  recommended 
in  ligaturing  the  common  carotid. 

The  Precautions. — Before  the  ligature  is  tied  the  following  facts  should 
be  carefully  observed :  1.  If  it  be  the  external  carotid  around  w^iich  the 
ligature  is  passed,  this  can  be  ascertained  by  raising  the  ligature  and  observ- 
ing the  effect  upon  the  circulation  of  the  facial.  2.  The  distance  of  the  seat 
of  the  ligature  from  collateral  branches ;  this  fact  can  only  be  determined 
by  carefully  exposing  the  vessel  for  half  an  inch  or  so  above  and  below  the 
seat  of  the  ligature.  If  vessels  be  found  within  this  extent,  they,  too,  should 
be  ligatured  independently  to  destroy  the  possibility  of  any  interference  with 
the  formation  of  the  internal  clot.  3.  That  the  ligature  be  not  carried 
around  the  external  and  internal  carotids  at  or  just  above  their  point  of 
bifurcation ;  if  it  be  around  both,  pressure  or  traction  will  check  the  pulsa- 
tion of  both ;  if  but  one,  it  will  control  only  the  circulation  of  the  vessel  acted 
upon.    Expose  and  clamp  the  common  facial  vein  early  in  the  operation. 

The  Fallacies. — Enlarged  lymphatic  glands  resting  on  the  vessel  may  be 
mistaken  for  it.  They  need  cause  but  momentary  thought,  since  their  cir- 
cumscribed outline  and  mobility  will  determine  their  nature.  If  enlarged, 
they- should  be  removed,  otherwise  they  can  be  pushed  aside.  The  superior 
thjToid  branch  may  be  confounded  with  the  lingual.  If  the  course  of  the 
respective  vessels  be  observed,  they  can  be  readily  distinguished  from  each 
other ;  the  superior  thyroid  arises  nearest  the  bifurcation,  arches  upward  and 
forward,  then  passes  quite  directly  dowaiward.  The  lingual  does  not  arch 
downward,  but  passes  upward  and  inward  to  gain  the  upper  border  of  the 
greater  cornu  of  the  hyoid  bone,  which  can  be  easily  outlined  by  the  finger. 


196 


OPERATIVE  SURGERY. 


The  Operation  above  ihe  Digastric. — Make  an  incision  from  the  lobule  of 
the  ear  to  the  greater  cornu  of  the  hyoid  bone,  along  the  anterior  border  of 
the  sterno-mastoid,  carefully  avoiding  the  parotid  gland.  Divide  the  super- 
imposed tissues  as  before,  down  to  the  digastric  muscle;  pull  it,  together 
with  the  stylo-hyoid,  downward,  and  if  the  jugular  vein  be  in  the  way,  push 
it  outward,  and  pass  the  ligature  from  without  inward. 

Tlie  Results. — Of  143  cases  of  ligature  of  one  external  carotid,  20  died ; 
91  were  done  before  asepsis,  with  16  deaths ;  of  51  done  under  asepsis,  4  died ; 
of  15  simultaneous  ligatures  of  both  external  carotids,  under  asepsis,  1  died. 

Ligature  of  the  Internal  Carotid  Artery. — The  internal  carotid  artery  is 
tied  sometimes  at  either  side  of  the  bleeding  point,  to  arrest  haemorrhage. 

The  Anatomical  Points. — The  internal  carotid  begins  at  the  bifurcation 
of  the  common  carotid,  at  or  a  little  above  the  upper  border  of  the  thyroid 
cartilage,  and  passes  perpendicularly  upward  in  front  of  the  transverse 
processes  of  the  three  upper  cervical  vertebrae,  to  the  carotid  foramen  in 
the  petrous  portion  of  the  temporal  bone,  through  which  it  enters  into  the 
cranial  cavity.  At  its  origin  and  in  the  lower  portion  of  its  course  it  is 
comparatively  superficial,  and  lies  externally  and  posteriorly  to  the  external 
carotid  artery. 

The  Contiguous  Anatomy. 


The  Relations  of  the  Internal  Carotid  Artery. 
In  front. 
Skin,  superficial  and  deep  fasciiB. 
Platysma. 

Parotid  gland  (above  the  angle  of  the  jaw). 
Stylo-glossus  and  stylo-pharyngeus  muscles. 
Glosso-pharyngeal  nerve. 
Hypoglossal  nerve. 


(Gray.) 


Externally. 

Internal  jugular  vein. 
Pneumogastric  nerve. 


Internally. 
Pharynx. 

Superior  laryngeal  nerve. 
Ascending  pharyngeal 

artery. 
Tonsil. 


j  Internal  carotid 
]  artery. 

Behind. 
Rectus  capitis  anticus  major. 
Sympathetic. 
Superior  laryngeal  nerve. 

The  linear  and  muscular  guides  of  the  external  carotid  artery  are  suita= 
bly  adapted  to  properly  locate  the  internal  carotid. 

The  angle  of  the  jaw  is  located  directly  externally  to  the  tonsil,  and  it 
therefore  may  become  a  practical  iony  gitide  to  the  incision  for  ligaturing 
the  artery  in  this  situation.  Although  it  may  he  ligatured  in  any  part  of 
the  course  between  its  origin  and  the  angle  of  the  lower  jaw,  still  the  point 
of  election  is  that  just  above  the  bifurcation.  It  may  become  necessary  to 
ligature  this  artery  on  account  of  a  penetrating  wound  received  from  without 
or  from  within  the  mouth.  Ulcerations  of  and  operations  on  the  tonsils 
have  been  complicated  with  injuries  to  this  vessel  that  have  caused  death 


THE   LIGATURE   OP   ARTERIES.  I97 

from  hfiemorrhage.  It  is  therefore  very  important  to  recall  the  relations 
of  the  tonsil  and  pillars  of  the  pharynx  to  this  artery,  in  connection  with 
all  injuries  and  morbid  processes  of  their  structures. 

The  Operation. — The  position  of  the  neck  of  the  patient  and  the  location 
of  the  primary  incision  are  similar  to  those  for  the  ligaturing  of  the  external 
carotid.  The  respective  tissues  are  carefully  divided  on  a  director  down  to 
the  muscles,  which  are  separated  and  pulled  aside,  and  the  ligature  is  passed 
from  without  inward,  carefully  avoiding  the  jugular  vein  and  the  pneumo- 
gastric  nerve  at  the  outer,  and  the  pharynx  at  the  inner  side. 

The  Fallacies. — The  internal  carotid  may  arise  from  the  arch  of  the  aorta, 
and  when  this  occurs  haBmorrhage  from  it  can  be  checked  only  by  ligaturing 
the  internal  carotid  itself.  If  but  one  ligature  be  applied  to  the  internal 
carotid  for  haemorrhage,  or  if  the  common  carotid  be  ligatured  alone  for  the 
same  reason,  the  collateral  circulation  may  cause  a  continuation  of  the  bleed- 
ing. A  ligaturing  of  the  internal  carotid  at  both  sides  of  the  bleeding  point 
is  the  only  certain  means  of  arresting  the  hsemorrhage  permanently.  The 
internal  carotid  may  lie  internal  to  the  external  carotid.  It  may  be  tortuous, 
or  even  be  absent. 

Tlie  Results. — This  vessel  has  been  tied  singly  several  times;  with 
either  the  common  or  external  carotid,  or  both,  fifteen  times.  Six  of 
these  patients  died,  from  causes  demanding  the  operation.  Simultane- 
ous ligature  caused  death  in  15  per  cent  of  the  cases  from  cerebral 
sequels. 

Ligature  of  the  Superior  Thyroid  Artery. — The  superior  thyroid  is  liga- 
tured in  the  removal  of  some  morbid  growths  and  for  the  arrest  of  bleeding 
due  to  direct  injury  of  the  structure. 

The  Anatomical  Points. — The  superior  thyroid  vessel  comes  from  the 
external,  or  from  the  common  carotid  near  the  point  of  its  bifurcation.  It 
passes  upward  and  forward,  at  first  quite  superficially,  then  runs  downward 
and  less  superficially  to  enter  the  thyroid  gland.  The  artery  is  closely  asso- 
ciated with  the  superior  laryngeal  nerve.  The  vessel  may  be  absent,  single, 
or  double  in  arrangement. 

The  Opei'ation. — Make  an  incision  about  three  inches  in  length  along  the 
anterior  border  of  the  sterno-mastoid,  its  center  corresponding  to  a  point 
opposite  the  thyro-hyoid  space.  The  carotid  sheath  should  be  exposed  as 
in  the  ligature  of  the  carotid,  and  the  artery  sought  for  along  the  inner  bor- 
der (Fig.  216).  The  ligature  is  applied  near  to  the  origin  of  the  vessel  or 
close  to  the  larynx,  the  latter  being  the  better  situation.  Cautiously  avoid 
the  superior  laryngeal  nerve. 

Ligature  of  the  Lingual  Artery.— The  lingual  artery  is  ligatured  more 
often  to  control  hsemorrhage  during  removal  of  the  tongue  than  for  any 
other  purpose. 

The  Anatomical  Points.— The  lingual  artery  arises  from  the  external 
carotid  opposite  the  hyoid  bone,  about  three  quarters  of  an  inch  above  the 
bifurcation  of  the  common  carotid,  and  runs  upward  and  inward  to  about 
a  quarter  of  an  inch  above  the  upper  border  of  its  greater  cornu,  passes  hori- 
zontally inward  parallel  with  it,  resting  upon  the  middle  constrictor  of  the 
15 


198  OPERATIVE  SURGERY. 

pharynx,  and  covered  first  by  the  digastric  and  stylo-hyoid  muscles,  and 
more  internally  by  the  hyoglossus  muscle.  It  then  ascends  between  the 
hyoglossus  and  genio-hyoglossus  muscles,  and  terminates  in  the  ranine  artery. 

It  has  no  superficial  muscular  guide;  a  linear  guide  may  be  drawn  paral- 
lel with  and  a  fourth  of  an  inch  above  the  greater  cornu  of  the  hyoid  bone 
(Fig.  214,  /) ;  practically,  however,  the  upper  border  of  the  greater  cornu  of 
the  hyoid  bone  marks  its  location.  The  vessel  caji  he  ligatured  at  three 
situations:  1,  At  the  apex  of  the  greater  cornu;  3,  between  the  greater 
cornu  and  the  posterior  belly  of  the  digastric;  3,  in  the  triangle  made  by 
the  digastric  and  mylo-hyoid  muscles  and  hypoglossal  nerve. 

The  Ligature  at  the  First  Situation. — In  this  situation  the  vessel  is 
tied  between  the  point  of  origin  and  the  tip  of  the  greater  cornu  of  the 
hyoid  bone  (Figs.  216  and  229). 

The  Operation. — Make  an  incision  three  inches  in  length  running  ob- 
liquely downward  and  forward  as  for  ligature  of  external  carotid,  its  center 
corresponding  to  the  greater  cornu.  The  various  tissues  are  carefully  divided, 
as  for  ligature  of  the  external  carotid,  and  the  hypoglossal  nerve  is  exposed. 
The  numerous  veins  located  in  the  course  are  now  pushed  aside,  and  the 
artery  carefully  sought  for  at  the  point  of  the  cornu  and  ligatured.  This 
operation,  on  account  of  the  absence  of  a  definite  deep  guide  to  the  location 
of  the  vessel,  and  the  uncertainty  of  its  point  of  origin,  together  with  the 
great  number  of  large  veins  in  the  course  of  the  search,  is  much  less  feasible 
than  either  of  the  other  two.  While  ligature  at  this  portion  controls  the 
circulation  of  the  dorsalis  linguse,  yet  the  difficulty  attending  the  step  is  in 
excess  of  the  advantages  gained  by  its  employment. 

The  Ligature  at  the  Second  Situation. — Place  the  patient  on  the  back, 
and  turn  the  head  to  the  opposite  side ;  carefully  define  the  greater  cornu  of 
the  hyoid  bone.  If  the  neck  be  fleshy  this  will  be  somewhat  difiicult.  The 
cornu  can  be  made  more  prominent  on  the  side  of  the  operation  by  pushing 
against  the  body  of  the  bone  on  the  opposite  side,  being  careful  to  press  the 
bone  directly  toward  the  cornu,  otherwise  the  operator  maybe  misled.  After 
the  patient  is  thoroughly  anaesthetized  (to  prevent  spasmodic  movements  of 
the  muscles  attached  to  the  hyoid  bone)  make  a  slightly  concave  incision 
just  above  and  along  the  upper  border  of  the  greater  cornu  of  the  hyoid 
boue,  downward  and  outward  to  nearly  the  anterior  border  of  the  sterno- 
mastoid  muscle,  about  three  inches  in  length  (Fig.  214,  /).  Divide  the 
superficial  fascia,  platysma,  and  deep  fascia  on  a  director ;  draw  upward 
the  submaxillary  gland  and  divide  the  deep  aponeurosis  transversely,  when 
the  digastric  and  stylo-hyoid  muscles  and  the  hypoglossal  nerve  will  be 
exposed.  Accurately  locate  the  greater  cornu  with  the  finger,  and  fix  and 
drag  it  forward  into  the  wound  with  a  tenaculum ;  draw  up  the  digastric 
and  the  stylo-hyoid  muscles  and  hypoglossal  nerve  with  a  blunt  hook ;  push 
aside  the  lingual  vein  if  seen,  and  pick  up  the  fibers  of  the  hyoglossus 
with  forceps,  and  incise  them  for  three  quarters  of  an  inch  in  the  direc- 
tion of  the  external  incision,  about  a  quarter  of  an  inch  above  the  greater 
cornu ;  beneath  them  will  be  found  the  vessel,  sometimes  accompanied  by 
the  lingual  vein.     Ordinarily  the  vessel  will  "  elbow  "  itself  into  the  incision 


THE   LIGATURE   OF  ARTERIES. 


199 


as  soon  as  all  the  intervening  muscular  fibers  are  divided  (Fig.  229).  Pass 
the  needle  from  the  vein.  Before  tying  ascertain  if  traction  on  the  liga- 
ture will  stop  the  pulsation  of  the  artery. 


HYPOGLOSSAL.  N. 
EXT  JUGULAR  V 
E}iT.CAROTID   A. 
FACIAL  A. 

GREAT  CORNU  OF  HYO ID   B 
SUBMAXILLARY  6LAN0 
DIGASTRIC  &  SlYLO-HYOID. 

UNGUAL  A 


SUBMAXILLARY  GLAND. 
MYLO-HYOIDEUS   M, 


DIGASTRICUS  M 


Fig.  229.— Ligature  of  lingual  artery.     First  and  second  situations. 

The  Ligature  in  the  Third  Situation. — The  third  situation  is  often 
called  "  the  place  of  election."  Make  an  incision  transversely  two  inches 
long,  concavity  upward,  and  its  center  just  within  the  middle  of  the  greater 
cornu  of  the  hyoid  bone.  Divide  the  integument,  superficial  fascia,  and 
platysma,  carefully  avoiding  the  superficial  veins ;  sever  the  deep  fascia  and 
pull  upward  the  submaxillary  gland,  when  the  posterior  belly  of  the  digastric 
will  come  into  view,  as  will  also  the  posterior  border  of  the  stylo-hyoid  muscle, 
the  mylo  -  hyoid  muscle, 
and  the  hypoglossal  nerve, 
accompanied  usually  by 
the  lingual  vein  (Fig. 
230).  Carefully  outline 
the  triangle  before  men- 
tioned ;  pinch  up  the  fi- 
bers of  the  hyoglossus, 
and  divide  them  midway 
between  the  hyoid  bone 
and  the  nerve,  when  the 
artery  will  be  seen  be- 
neath. Separate  it  from  the  vein  if  the  vein  lie  beneath  the  muscle,  and 
pass  the  ligature  from  above  downward. 

The  Fallacies. — The  hypoglossal  nerve  may  be  mistaken  for  the  artery. 
The  nerve  rests  on  the  hyoglossus,  the  artery  runs  hejieath  it.  These  facts, 
together  with  the  pulsation  of  the  artery  and  other  distinctive  anatomical 
features,  should  render  the  discrimination  easy.     It  is  well  to  know,  however. 


LNGUAL  ARTERY. 

■HYO-GLOSSUS.M.{CUT.) 

\hYP0-GL0S5AL  nerve  WITH  VEIN. 

Fig.  230. — Ligature  of  lingual  artery.     Third  situation. 


200  OPERATIVE  SURGERY. 

that  the  movements  of  the  tissues  dependent  on  the  acts  of  respiration  make 
it  somewhat  difficult,  and  often  impossible,  to  detect  the  arterial  impulse. 
If,  however,  the  supposed  artery  be  carefully  isolated,  the  ligature  passed 
around  it,  and  a  good  light  thrown  into  the  wound,  its  tortuous  outline  will 
be  noticed  with  each  pulsation.  The  pulsation  can  be  seen  best  in  the  inter- 
val of  the  respiratory  acts  when  the  tissues  are  quiet.  However,  firm  fixation 
and  forward  traction  of  the  cornu  by  means  of  a  tenaculum  will  prevent 
movements  of  the  tissues,  render  them  superficial,  and  otherwise  greatly  aid 
in  the  exposure,  recognition,  and  ligature  of  the  vessel. 

The  lingual  vein  may  be  mistaken  for  the  artery,  especially  in  old  people 
with  heart  lesions,  as  in  old  age  the  coats  of  the  vein  are  usually  much  thick- 
ened, and  pulsation  in  the  vein  may  attend  heart  disease.  The  vein  some- 
times runs  with  the  artery  behind  the  hyoglossus  muscle ;  more  frequently, 
however,  it  rests  on  this  muscle.  It  has  the  characteristic  color  of  a  vein, 
and  is  larger  than  the  artery.  The  lingual  artery  may  be  absent,  run  higher 
than  common,  or  lie  in  the  structure  of  the  hyoglossus.  After  the  division 
of  the  fibers  of  the  hyoglossus  muscle  the  search  for  the  vessel  must  be  con- 
ducted cautiously  to  avoid  opening  into  the  pharynx.  If  the  vessel  can  not 
be  found  above  the  cornu,  and  ligation  be  imperative,  it  should  be  sought 
for  at  the  origin. 

The  Results. — This  artery  has  been  tied  repeatedly  with  great  advantage, 
for  the  purpose  of  controlling  hsemorrhage  from  the  tongue  and  delaying 
the  development  of  morbid  growths  of  that  structure. 

Ligature  of  the  Facial  Artery. — The  facial  artery  is  one  of  the  large 
branches  of  the  external  carotid,  and  is  divided  into  a  cervical  and  facial 
part. 

The  Anatomical  Points. — The  artery  arises  just  above  the  tip  of  the 
greater  cornu,  or  about  an  inch  from  the  bifurcation  of  the  common  carotid, 
passes  forward  and  upward  beneath  the  horizontal  ramus  of  the  lower  jaw, 
going  through  the  substance  of  the  submaxillary  gland,  and  gains  the  ex- 
ternal surface  of  the  ramus  at  the  anterior  inferior  angle  of  the  masseter 
muscle,  lying  there  in  a  groove  at  the  outer  border  of  the  bone.  The  masse- 
ter, therefore,  is  the  muscular  guide  at  this  portion  of  the  course  of  the 
vessel.  It  may  be  ligatured  at  three  situations — in  the  neck,  and  as  it 
crosses  the  ramus  of  the  jaw  and  near  the  angle  of  the  mouth,  the  second 
being  the  best  situation. 

The  Operation  in  the  Nech. — The  head  is  turned  to  the  opposite  side, 
and  an  incision  of  about  three  inches  in  length  is  made  obliquely  downward 
and  forward  a  little  in  front  of  the  anterior  border  of  the  sterno-mastoid,  its 
center  being  at  a  point  about  a  third  of  an  inch  above  the  tip  of  the  greater 
cornu  (Fig.  316).  The  dissection  is  carefully  made,  as  in  ligaturing  the 
lingual  at  the  first  portion,  by  pushing  aside  the  facial  and  other  contiguous 
veins,  drawing  up  the  digastric,  and  passing  the  ligature. 

The  Operation  at  the  Ramus  of  the  Jaw. — Place  the  patient  as  before ; 
draw  the  integument  upward  over  the  ramus,  so  that  when  retraction  of  the 
tissues  occurs  the  cicatrix  will  fall  beneath  the  jaw ;  make  an  incision  about 
two  inches  in  length  along  the  border  of  the  jaw ;  divide  the  tissues  on  a 


THE  LIGATURE   OF   ARTERIES. 


201 


director  (Figs.  214,  c,  and  217)  down  to  the  vessel,  isolate  it,  and  pass  the 
ligature  from  behind  forward  away  from  the  vein.  If  a  resulting  cicatrix 
be  of  no  moment,  the  primary  incision  can  be  made  in  the  long  axis  of  the 
vessel  along  the  anterior  inferior  angle  of  the  masseter  muscle  (Fig.  214,  c). 
It  is  rarely  tied  at  the  angle  of  the  mouth  (Fig.  313). 

The  Fallacies. — At  its  origin  this  vessel  may  be  mistaken  for  the  lingual. 
Interruption  of  the  circulation  will  easily  make  the  distinction  if  the  respec- 
tive areas  of  supply  be  examined. 

Ligature  of  the  Temporal  Artery, — The  temporal  artery  is  one  of  the 
terminal  branches  of  the  external  carotid. 

The  Anatomical  Points. — The  temporal  artery  begins  in  the  substance 
of  the  parotid  gland  between  the  neck  of  the  lower  jaw  and  the  external 
meatus,  and  passes  upward  across  the  root  of  the  zygoma,  subcutaneously, 
where  its  pulsation  can  be  distinctly  felt.  About  two  inches  above  the 
zygomatic  process  it  divides  into  its  terminal  branches.  This  artery  has  no 
muscular  guide.     The  zygomatic  process  is  the  hony  guide. 

The  Operation  (Fig.  214,  d). — Make  an  incision  in  the  line  of  the  vessel, 
as  indicated  by  its  pulsation,  an  inch  in  length  ;  about  one  fourth  of  an  inch 
in  front  of  the  tragus  divide  the  skin  and  fascia ;  avoid  the  vein  lying  be- 
hind the  artery,  the  temporo-facial  nerves  lying  in  front,  and  the  auriculo- 
temporal nerve  beneath  the  vessel ;  expose  the  vessel  and  pass  the  needle 
from  behind  forward  (Fig.  313). 

Ligature  of  the  Occipital  Artery. — The  occipital  artery  is  often  severed 
in  injuries  of  the  scalp. 

The  Anato7nical  Points. — The  occipital  artery  arises  from  the  external 
carotid  a  trifle  above  the  facial,  and  passes  upward  and  outward  to  the  inter- 
val between  the  transverse  process  of  the  atlas  and  the  mastoid  process  of 


STERNO-MASTOID    M. 
SMALL  OCCIPITAL  N. 
,COMPLEXUS    M. 
I     I  SPLENIUS   M. 

OCCIPITAL   A. 

GREAT  OCCIPITAL  N 
TRAPEZIUS  M. 


TRAPEZIUS   M 
SPLENIUS   CAPITIS  M 

COM  PLEXUS    M 
OBLiqUUS  CAPITIS  SUP.  M 

GRE/n-  OCCIPITAL  N 
OBUQUUS  CAPITIS  INF.  A/f/ 
TRACHELO-MASTOID  M. 
SMALL  OCCIPITAL   N 
STERNO'MASTOID   M 


Fig.  231. — Occipital  artery  and  great  occipital  nerve. 


the  occipital  bone.     It  then  passes  over  the  posterior  portion  of  the  skull 
midway  between  the  external  occipital  protuberance  and  the  mastoid  process 


202  OPERATIVE  SURGERY. 

(Fig.  214,  e).  It  has  no  intimate  hony  or  muscular  guide.  It  is  tied  at  its 
origin  and  behind  the  mastoid  process. 

The  Operation  at  the  Origin  (Fig.  216). — Make  an  incision  along  the 
anterior  border  of  the  sterno-mastoid,  about  three  inches  in  length,  the  cen- 
ter corresponding  to  a  point  a  little  above  the  apex  of  the  greater  cornu  of 
the  hyoid  bone.  Divide  the  superficial  tissues  carefully  on  a  director,  sepa- 
rate the  areolar  tissue  with  its  blunt  extremity,  push  aside  the  veins,  and  find 
the  posterior  belly  of  the  digastric.  A  little  below  will  be  seen  the  ninth 
nerve  winding  around  the  object  of  search.  Pass  the  needle  from  the  nerve. 
The  relation  between  the  hypoglossal  nerve  and  the  vessel  is  constant,  irre- 
spective of  the  deviations  from  normal  in  other  regards  of  either  of  these 
structures.  Very  rarely,  indeed,  the  occipital  artery  arises  from  the  internal 
carotid. 

The  Operation  behind  the  Mastoid  Process  (Fig.  231). — Make  a  trans- 
verse incision  about  two  inches  in  length,  beginning  half  an  inch  behind  and 
a  little  below  the  mastoid  process  and  extending  inward.  Divide  the  integu- 
ment and  attachments  of  the  sterno-mastoid  and  the  splenius  muscles;  feel 
for  the  pulsation  at  the  bottom  of  the  wound.  Isolate  the  artery  and  pass 
the  ligature. 

SPECIAL    OPERATIONS    ON   ARTERIES. 

Extirpation  of  Aneurism. — Latterly  the  extirpation,  especially  of  trau- 
matic aneurisms  mainly  of  the  arterio-venous  type,  has  been  given  much 
thought,  and  experience  prompts  the  belief  that  this  operation  is  a  method 
of  practice  to  be  commended.  Naturally  the  technique  is  considerably 
varied  by  the  seat  and  size  of  the  vessel  involved.  The  following  is  illus- 
trative of  the  procedure  as  practiced  by  Matas  *  in  the  case  of  an  arterio- 
venous aneurism  of  the  subclavian  performed  nine  days  after  the  injury. 

The  Operation. — For  the  purposes  of  systematic  description  Matas 
divided  this  operation  into  seven  stages. 

The  First  Stage. — Free  infiltration  of  tissues  overlying  the  clavicle 
with  Schleich's  No.  1  solution  followed  by  denudation  of  the  clavicle  of 
periosteum  and  the  making  of  two  holes  at  either  side  of  the  junction  of  the 
middle  and  outer  thirds  of  the  bone  and  its  division  at  that  point  with  a 
Gigli  saw. 

The  Second  Stage. — Free  eucain  infiltration  of  tissues  below  and  about 
the  seat  of  the  procedure  followed  by  the  formation  of  an  osteo-plastic  flap 
beginning  at  the  line  of  section  of  the  bone,  going  downward  two  inches, 
then  inward  and  upward  crossing  the  right  sterno-clavicular  joint  to  the 
median  line  of  the  neck,  ending  at  the  lower  border  of  the  thyroid  cartilage. 
Disarticulation  of  the  clavicle  and  oedematous  infiltration  with  solution  of 
eucain. 

The  Third  Stage. — The  dissection  and  elevation  of  the  flap,  exposing 
the  sterno-thyroid  and  sterno-hyoid  muscles  and  the  superficial  veins  of 
that  region.     A  rest  of  ten  minutes  with  heart  stimulants  given. 

*  Transactions  American  Surgical  Association,  1903. 


THE   LIGATURE   OP   ARTERIES  203 

The  Fourth  Stage. — The  division  and  removal  of  the  suhclaviiis  muscle 
followed  by  careful  exposure,  recognition  and  preparatory  securing  of  the 
veins  of  the  region. 

The  Fifth  Stage. — This  stage  was  directed  to  the  exposure  of  the  arte- 
rial trunks  at  the  proximal  aspect  of  the  aneurism.  The  innominate  being 
absent,  the  first  portion  of  the  subclavian  was  controlled  by  a  temporary 
traction  loop.     Chloroform  was  given. 

The  Sixth  Stage. — "The  detachment  of  the  subclavian  vein  from  the 
artery  at  the  point  of  injury  after  failure  to  identify  the  third  portion  of 
the  vessel  outside  the  scalenus  anticus  on  account  of  a  mass  of  exudate 
which  masked  it  completely.  Profuse  hsemorrhage  from  the  artery  at  the 
anastomotic  orifice  in  spite  of  complete  control  of  this  vessel  at  its  origin. 
Final  ligation  of  the  artery  at  each  side  of  the  bleeding  point.  Closure 
of  the  venous  orifice  by  suture  without  obstructing  its  lumen." 

The  Seventh  Stage  consisted  in  the  readjustment  of  the  flap,  drainage 
and  closure  of  the  wound. 

The  subject  of  this  unusually  difficult  case  made  a  good  recovery. 

The  Results. — Matas  reports  15  analyzed  cases,  11  of  which  were  treated 
expectantly.  Of  these  latter  one  died  from  hemorrhage  after  healing  of 
the  wound,  three  weeks  later.  The  remaining  ten  recovered.  Four  were 
operated  on,  three  within  13  days,  all  recovered;  one  after  32  years,  for 
aneiirismal  complications,  who  died. 

Moynihan  *  in  1897  extirpated  a  spontaneous  aneurism  of  the  sub- 
clavian.    Secondary  haemorrhage  on  the  fifty-ninth  day  after  the  operation 


/ 


Fig.  332. — The  bony  landmarks  and  the  outlines  of  flaps  for  extirpation  of  aneurism 
and  for  subsequent  ligature  of  innominate. 

requiring  ligature  of  the  innominate,  which  was  followed  by  death  of  the 
patient  in  a  few  hours. 

The  Operation. — A  curved  incision  with  the  convexity  downward  was 
made,  commencing  over  the  trapezius  muscle  internal  to  and  above  the 

*  Annals  of  Surgery,  July,  1898. 


204 


OPERATIVE    SURGERY. 


Pig.  233. — The  flaps  reflected,  showing  subclavian  vessels, 
scalenus  muscle,  phrenic  nerve,  and  brachial  plexus. 


acromio-clavicular  joint  and  ending  above  and  external  to  the  sterno- 
clavicular joint,  its  lowest  point  being  about  one  and  a  half  inches  below 
the  center  of  the  clavicle  (Fig.  233) ,  The  flap  thus  marked  out  was  reflected 
upward,  and  the  full  extent  of  the  subclavian  triangle  exposed  (Fig.  233). 
The  outer  half  of  the  claviciilar  attachment  of  the  sterno-mastoid  muscle 
was  divided  about  three-fourths  of  an  inch  above  the  clavicle,  leaving 

sufficient  of  the  muscle 
attached  to  the  bone  to 
enable  the  divided  fibres 
to  be  readily  stitched 
after  the  completion  of 
the  operation.  The  clav- 
icle being  cleared  on  its 
anterior  surface,  four 
holes  were  now  drilled 
through  it,  two  about 
half  an  inch  apart,  at  a 
distance  of  one  and  a 
half  inches  from  the 
sterno-clavicular  articu- 
lation, and  two,  the  same 
distance  apart,  at  the 
junction  of  the  middle 
and  outer  thirds  of  the 
bone.  Between  the  inner  two  and  between  the  outer  two  the  bone  was  sawn 
through  by  Hey^s  saw,  and  the  middle  portion,  connected  with  the  sub- 
clavius  muscle,  liberated.  Eound  the  bone  a  large  curved  Hagedorn  needle 
threaded  with  a  fairly  stout  silk  traction  loop  was  passed,  by  means  of  which 
the  mid  portion  of  the  clavicle  was  pulled  downward  (Fig.  233).  The 
aneurismal  sac  was  now  exposed  and  cleared,  and  the  dissection  to  expose 
the  outer  edge  of  the  anterior  scalenus,  and  the  artery  beneath  it,  was  com- 
menced. After  a  brief  and  somewhat  tedious  clearing  of  parts,  during  which 
a  vein  was  divided  about  one-fourth  inch  from  its  junction  with  the  sub- 
clavian vein  and  ligatured,  the  scalenus  anticus  was  well  exposed.  It  was 
now  seen  that  the  aneurismal  swelling  began  almost  exactly  at  the  outer 
border  of  the  scalenus,  and  on  raising  this  latter  with  a  retractor  the  second 
portion  of  the  subclavian  artery  was  readily  exposed.  The  phrenic  nerve 
lying  on  the  scalenus  was  quite  distinctly  visible  (Fig.  233). 

There  was  no  difficulty  in  passing  an  ordinary  aneurism-needle  threaded 
with  four  strands  of  thoroughly  well-sterilized  .00  catgut  round  the  second 
portion  of  the  vessel,  and  tying  tight  at  a  distance  of  about  one-third  inch 
from  the  aneurism.  Between  this  ligature  and  the  sac  a  thin  silk  ligature 
was  passed  and  tied  as  close  up  to  the  sac  as  was  possible.  The  subclavian 
artery  was  then  cut  through  between  these  ligatures,  and  the  aneurism 
freed  on  its  inner  side.  All  adhesions  to  the  sac  were  now  rapidly  and 
very  easily  stripped  away,  and  the  dissection  carried  on  till  the  first  part 
of  the  axillary  artery  was  reached.     This  was  ligatured  with  catgut  in  the 


THE   LIGATURE   OP   ARTEHIES. 


205 


same  manner  as  the  subclavian,  at  a  distance  of  about  one  inch  from  the 
aneurism.  On  cutting  the  vessel  through  internal  to  the  ligature  the 
aneurism  was  free,  and  was  removed,  and  the  mid  portion  of  the  clavicle, 
freed  from  its  silk  retractor,  replaced. 

Through  the  holes  previously  bored  in  the  bone  silver-wire  sutures  were 
passed,  and  the  loose  middle  fragment  thus  firmly  fixed  in  position.  The 
cut  portion  of  the  sterno-mastoid  was  sutured.  A  little  loose  iodoform- 
gauze  packing  was  passed  into  the  wound  from  the  outer  angle  of  the  flap, 
and  the  skin  wound  united  with  interrupted  sutures  of  silkworm  gut.  At 
the  end  of  the  operation  the  patient's  condition  was  excellent.  He  was 
put  to  bed  and  kept  lying  flat  on  his  back,  without  pillows. 

On  February  6th,  the  fifty-ninth  day  after  the  operation,  the  patient 
felt  "  something  burst,"  deep  in  his  neck.  Digital  pressure  and  the  sub- 
sequent application  of  a  pad  and  bandage  checked  the  haemorrhage  for  a 
time,  but  on  the  morning  of  February  8th  a  fresh  gush  of  blood  occurred. 
It  was  therefore  determined  to  open  up  the  subclavian  triangle  and  deal  with 
what  one  should  find.  A  terrific  haemorrhage  occurred  from  the  lower  and 
inner  part  of  the  subclavian  triangle.  The  forefinger  passed  down  in  this 
direction  entered,  at  a  great  depth,  an  aperture  in  the  subclavian  artery 
into  which  the  tip  of  the  finger  just  fitted.  To  reach  this  opening  from 
the  posterior  triangle  was  quite  impossible,  and  therefore  it  was  decided 
to  ligature  the  innominate  artery. 

A  curved  incision  was  made  with  the  convexity  to  the  left,  beginning 
about  two  and  a  half  inches  above  the  clavicle  over  the  sterno-mastoid 
muscle,  and  terminating  about  two  and  a  half  inches  below  the  clavicle, 
at,  approximately,  the  junction  of  its  inner  and  middle  thirds  (Fig.  232  a). 
The  incision  extended  to  the  left  sterno-clavicular  articulation.     The  flap 


Fig.  234. — The  flap  reflected,  bones  divided,  innominate  and  carotid  arteries  tied. 


so  outlined  was  turned  outward,  exposing  the  sterno-mastoid,  the  inner 
end  of  the  clavicle,  the  sterno-clavicular  articulation,  and  a  portion  of  the 
upper  end  of  the  sternum.  The  clavicle  was  then  pierced  with  two  holes 
about  half  an  inch  apart,  the  internal  one  being  at  a  distance  of  about  one 


206  OPERATIVE  SURGERY. 

inch  from  the  inner  extremity  of  the  bone.  Between  these  two  holes  the 
bone  was  divided  with  a  Hey's  saw.  A  piece  of  the  sternum  was  then 
outlined  and  removed  by  sawing  or  chiselling  from  the  upper  end  of  the 
cartilage  of  the  first  rib  to  the  middle  line  of  the  bone  or  a  little  beyond, 
and  from  the  end  of  this  incision  a  second  was  carried  upward  to  the  upper 
border  of  the  sternum  about  its  middle.  The  posterior  surface  of  the 
sternum  was  cleared  by  passing  the  finger  behind  it.  The  inner  end  of  the 
clavicle  and  the  piece  of  the  sternum  were  then  turned  upward,  and  access 
was  readily  given  to  the  innominate  artery  just  before  its  bifurcation  (Fig. 
234).  A  ligature  was  then  applied  without  the  least  difficulty,  and  with 
the  confident  assurance  that  no  neighboring  structures  were  included,  the 
bones  were  replaced. 

Tlie  Remarks. — Silver  wire  or  silkworm  gut  can  be  used  to  unite  and 
fix  the  divided  clavicle,  and  the  sternum  is  quite  easily  held  in  position  by 
a  few  silkworm-gut  or  catgut  sutures,  passed  through  its  periosteal  cover- 
ing. Though  my  patient  did  not  live  to  demonstrate  the  after-effects  of 
this  operation,  there  can  be  little  doubt  that  all  the  tissues  would  heal 
satisfactorily,  and  that  the  bony  union  would  eventually  be  complete  and 
sound. 

In  this  operation  I  ligatured  the  common  carotid,  and  subsequently  the 
innominate,  with  fine  silk.  The  patient,  in  spite  of  all  attempts  at  restora- 
tion, died  about  one  hour  after  the  completion  of  the  operation. 

Tiie  Results. — Souchon  *  reports  58  cases  of  spontaneous  aneurism  of 
the  third  portion  of  the  subclavian  with  only  8  recoveries.  Forty-three 
were  treated  with  proximal  ligature,  3  recovered;  6  by  distal  ligature, 
1  recovered;  6  by  amputation  at  shoulder- joint,  2  recovered;  2  by  opening 
sac,  1  recovered ;  1  by  extirpation,  with  recovery.  Halstead  f  and  Curtis 
have  each  recorded  a  successful  case. 

Aneurism  of  the  Extremities  of  common  or  arterio-venous  type  can  be 
treated  more  satisfactorily  by  extirpation  than  can  those  located  in  con- 
nection with  the  trunk.  In  the  former  instances,  after  controlling  the 
circulation  by  an  Esmarch's  bandage  or  other  means,  the  sac  is  exposed  in 
the  long  axis,  carefully  avoiding  injury  of  intervening  important  struc- 
tures; the  vessels  above  and  below,  mainly  contributing  to  its  growth,  are 
ligatured,  the  sac  opened  and  the  contents  removed. 

Ligature  of  apparent  collateral  branches  should  be  carefully  done  be- 
fore removal  of  the  constricting  agent,  which  latter  should  be  slowly  prac- 
ticed, supplemented  perhaps  with  digital  pressure,  so  as  to  permit  the 
catching  of  bleeding  points  as  they  may  become  manifest.  After  the  arrest 
of  hoemorrhage  the  sac  should  be  dissected  out  as  completely  as  may 
be  consistent  with  the  integrity  of  the  important  contiguous  structures. 
The  remaining  cavity  is  closed  by  means  of  buried  and  other  sutures, 
perhaps  a  drainage-tube  introduced,  and  the  wound  is  dressed  in  the  usual 
manner. 

*  Annals  of  Surgery,  1895. 

f  Bulletin  of  Johns  Hopkins  Hosp.,  July  and  August,  1893. 


THE   LIGATURE   OF  ARTERIES. 


20T 


The  Reniarhs. — Proximal  ligature  of  the  main  vessel  leading  to  the 
aneurism  should  be  practiced  when  other  means  of  control  are  not  feasible. 
The  introduction  from  within  the  sac  into  the  open  mouths  of  vessels  of 
such  exploring  agents  as  probes,  sounds,  etc.,  enables  one  to  locate  the 
vessels  and  the  better  secure  them  from  without  the  sac,  or  within  b}^  cir- 
cumscribing with  a  sharp  knife  their  open  mouths.  Portions  of  the  sac 
adherent  to  important  contiguous  structures  ought  not  to  be  removed  to 
the  detriment  of  the  tissues  in  question.  The  entire  limb  should  be  thor- 
oughly cleaned  in  approved  manner,  and  after  the  operation  wrapped  in 
cotton,  elevated,  and  the  circulation  noted  in  order  to  avoid  so  far  as  possi- 
ble the  occurrence  of  gangrene. 

Matas' Method  of  Radical  Cure  of  Aneurism.* — This  method  of  practice 
is  adapted  to  aneurisms  having  distinct  sacs  and  in  which  the  proximal 
end  of  the  vessel  constituting  the  aneurism  can  be  temporarily  controlled. 
Aneurisms  of  the  large  ves- 
sels of  the  extremities, 
whether  of  idiopathic  or 
traumatic  nature,  afford  a 
suitable  field  of  effort  in  this 
regard. 

The  Operation  {Fusi- 
form Aneurism). — Elevate 
the  limb  and  apply  Es- 
march's  bandage  or  other 
suitable  agent  so  as  to  arrest 
the  circulation  in  the  tumor ; 
expose  and  open  from  end 
to  end  through  a  free  inci- 
sion in  its  long  axis  the 
aneurismal  sac ;  retract  fully 
the  divided  borders  of  the 
sac;  evacuate  the  contents, 
exposing  the  interior  to 
view;  examine  carefully  the 
interior  for  collateral  open- 
ings, closing  those  that  bleed 
by  pressure  until  all  are 
securely  shut  by  sewing; 
scrub  gently  and  thoroughly 

with   o"auze   wet   with   saline   ^^^'  ^^^' — '^^^  interior  of  a  fusiform  aneurismal  sac, 
,    ,  .*'         ,,  •    ,      •  n         showing  openings  and  groove  of  main  vessel  and 

solution      the      interior      ot         opening  of  collateral  branch, 
the  sac,  removing  laminated 

blood  and  stimulating  the  surface  to  quicker  plastic  action  (Fig.  235),  close 
with  a  suitable  curved  needle  armed  with  chromicized  catgut  by  continuous 
or  interrupted  sutures  carried,  as  indicated  (Fig.  236),  through  the  borders 


*  Transactions  of  American  Surgical  Association,  1902. 


208 


OPERATIVE  SURGERY. 


of  the  two  main  openings  and  those  of  the  corresponding  intervening  wall  of 
the  sac ;  remove  all  agents  of  constriction  and  permit  restored  circulation  to 

test  the  security  of  the 
sewing ;  close  bleeding 
points  by  additional  su- 
tures if  needed,  and  in- 
troduce if  practicable  a 
second  row  of  sutures 
(Fig.  237),  thus  lessening 
the  size  of  the  cavity  and 
burying  the  first  row;  in- 
sert two  or  more  chromi- 
cized  catgut  sutures  into 
each  side  of  the  floor  of 
the  sac,  then  pass  their 
free  ends  through  the  in- 
folds of  the  sac  (Fig. 
238),  thence  through  the 
skin  to  the  external  sur- 
face (Fig.  239)  ;  unite 
the   free   borders    of   the 


Fig.  236. — The  fusiform  aneurism.  The  first  row 
of  sutures  iirmly  closing  the  orifices  by  fine 
chromicized  catgut  or  silk. 


skin  with  sutures  carried  so  as 
to  secure  the  line  of  union  to  the 
immediate  underlying  structures; 
tie  firmly  in  place  over  gauze  pads 
the  transfixion  sutures,  thus  com- 
pletely obliterating  the  sac  (Fig. 
347). 

In  the  Sacciform  Aneurism 
(Fig.  240)  the  single  opening  is 
closed  by  sewing  (Fig.  241), 
as  in  the  preceding  illustration 
(Fig.  242),  but  without  encroach- 
ing materially  on  the  diameter  of 
the  lumen  of  the  main  artery. 

The  Operation. — Expose,  open 
and  treat  the  aneurismal  sac  as 
in  the  operation  for  cure  of  fusi- 


FiG.  237.— The  fusiform  aneurism.  The 
second  row  of  sutures.  These  may  be 
the  interrupted  or  continued.  If  floor 
be  rigid  the  second  row  may  be  omitted. 


THE   LIGATURE   OP   ARTERIES. 


209 


form  aneurism  (Fig.  243)  ;  close  by  interrupted  or  continuous  sutures, 
passed  as  indicated  in  illustrations,  and 
without  or  with  the  introduction  of  the 
catheter  (Figs.  243,  244),  the  open- 
ings of  the  main  artery  (Fig.  245) ; 
practice  the  remaining  steps  of  the 
operation  as  in  the  preceding  one,  caus- 
ing the  outline  of  the  transverse  section 
to  conform  with  that  of  Fig.  246). 

The    Remarks. — This    method    of 
practice  does   not   interfere   with   the 
structures    contiguous 
to  the  sac,  as  in  extir- 
pation.   The  wound  is 
of  minimum  size  and 
cumscribed  boundaries, 
fluous  sac-wall  should  be  excised. 
Since   the   sac   is   nourished   by 
perivascular  structures,  as  little 
separation  of  it  as  possible 
should    take    place.      Vari- 
ous   agents    for    control    of 
ha?morrhage     can    be     util- 
ized    when     the     Esmarch 
bandage  is  not  suitable  for 
purpose.      Kangaroo    tendon 


with  cir 
Super 


the 
or 


1. — The  fusiform  aneurism. 
The  second  row  of  sutures  (continuous)  intro- 
duced :  the  final  obliterating  sutures  passed 
at  either  side.  On  tlie  left,  transfixion  of 
floor  is  made.  On  the  right,  ends  of  similar 
sutures  passed  through  integuments. 


Fig.  239. — The  fusiform  aneurism. 
The  deep  supporting  sutures  in  place,  and  passing  their 
ends,  through  skin  and  aneurismal  wall. 


silk  may  be  used 
instead  of  catgut. 
Carefully  record- 
ed experience 
should  be  consult- 
ed in  advance  of  opera- 
tion. 

Excision   of  the   Ex- 
ternal    Carotid      {Daw- 
ham). — This  measure  is 
practiced       not       infre- 
quently for  the  purpose 
of  inhibiting  the  growth 
of  inoperable  malignant 
and     other     tu- 
mors    nourished 
l)y    the    external 
carotid    and    its 
branches. 


210 


OPERATIVE  SURGERY. 


The  Operation. — Raise  the  patient's  shoulders,  extend  the  head  and 
turn  the  face  to  the  opposite  side;  make  a  curved  incision  from  near  the 
level  of  the  tip  of  the  ear  downward  closely  behind  the  angle  of  the  jaw, 


Fig.  340. — The  sacciform  aneurism,  its 
main  orifice  and  the  dotted  outline  of 
the  main  vessel. 


Fig.  241. — The  sacciform  aneurism.  The 
closure  of  main  orifice  by  continuous  su- 
tures without  special  removing  of  lumen. 


forward  to  the  greater  cornua  of  the  hyoid  bone;  expose  and  identify  the 
superior  thyroid  branch  by  its  course  and  its  relations  to  the  bifurcation 
of  the  common  carotid,  passing  a  ligature  around  the  external  carotid  and 
leaving  it  untied;  trace  the  external  carotid  upward,  or  the  common  and 
internal  in  the  absence  of  the  former,  tying  twice  each  branch  in  the  order 
of  exposure,  dividing  each  between  the  ligatures;  expose  the  terminal 
branches  as  high  above  the  digastric  muscle  as  practicable,  carrying  a  liga- 
ture around  each;  tie  the  ligature  already  passed  around  the  external 
carotid,  also  those  Qf  the  terminal  branches ;  sever  the  vessels  ligatured  and 
remove  the  intervening  trunk. 

The  Comments. — The  removal  quite  simultaneously  of  both  external 
carotids  much  the  better  meets  the  indications.  The  absence  of  a  well- 
detined  external  carotid  may  give  rise  to  confusion.  The  primary  brauches, 
especially  of  the  lingual,  may  be  tied.     Careful  asepsis  is  essential  in  the 


THE  LIGATURE  OP   ARTERIES. 


211 


entire  measure.  Dr.  Dawbarn  sometimes  uses  a  blunt  probe  instead  of  an 
aneurism-needle  to  secure  the  vessels;  oftener,  however,  he  places  the  liga- 
tures by  means  of  his  curved  artery  forceps.  The  occipital,  superior  thy- 
roid and  facial  arise  sometimes  from  the  internal  carotid  and  common 
carotid,  respectively. 

The  Results. — There  seems  to  be  no  doubt  that  this  method  of  pro- 
cedure delays  and,  possibly  in  rare  instances,  arrests  the  growth  of  inopera- 
ble tumors  which  might  otherwise  cause  prompt  death.  Also  it  reduces 
to  a  minimum  the  loss  of  blood  in  operable  cases,  and  no  doubt  inhibits 
the  local  return  of  the  disease  in  such  instances,  Dawbarn  reports  a 
primary  operative  fatality  of  2  in  48  instances. 


Fig.  243.— The  sacciform  aneurism.     Closure  of  the  main  orifice  by  interrupted  sutures 
"without  special  removing  of  lumen. 

Arteriorrliaphy,  or  suture  of  an  artery  for  repair  or  injury  to  the  vessel, 
is  advisable,  especially  when  closure  of  the  vessel  by  ligature,  as  is  common 
in  such  cases,  exposes  the  patient  to  increased  danger.  If  the  suturing  be 
carefully  practiced,  the  patient  is  given  the  advantages  of  increased  oppor- 
tunity without  additional  danger.  The  wounds  vary  in  direction  and 
extent,  and  are  the  outcome  of  common  and  operative  traumatism. 

The  Operation. — Under  strict  aseptic  care  and  complete  control  of  the 
circulation  expose  the  vessel  at  the  seat  of  injury,  cautiously  preserving  the 


^ 


Fig.  243. — The  sacciform  aneurism.  Ob- 
literation of  orifice  completed,  lumen 
intact.  Operation  completed  as  in  fusi- 
form aneurism. 


Fig.  244. — Tlie  sacciform  aneurism,  with 
catheter  introduced  to  maintain  cali- 
ber of  lumen;  sutures  placed  over 
catheter. 


Fig.  245. — The  sacciform  aneurism.    The  removal  of  catheter  before  final  closure  of  the 

main  channel. 


THE  LIGATURE  OF  ARTERIES. 


21J 


integrity  of  its  sheath.    In  longitudinal,  oblique  and  in  transverse  injuries 
not  exceeding  more  than  half  its  circumference  transfix  in  turn,  about  a 


Fig.  246. — The  sacciform  aneurism.  Trans- 
verse section.  1.  The  line  of  sutures 
closing  the  orifice  over  catheter — new 
lumen  (Fig.  244);  2.  The  second  row 
of  sutures  reducing  size  of  sac  (Figs. 
237  and  238);  3.  The  supporting  ob- 
literative  sutures  that  bring  in  contact 
the  floor  and  roof  of  aneurismal  sac 
(Figs.  238  and  239);  J^.  (Krauze  pads 
under  obliterative  sutures ;  5,  Super- 
ficial integumentary  sutures. 


Fig.  247. — The  fusiform  aneurism.  Trans- 
verse section.  1.  First  row  of  oblit- 
erating sutures  (Fig.  236);  2.  Second 
row  covering  the  first  (Fig.  237) ;  3.  In- 
verted sac  walls ;  4-  Supporting  oblit- 
erative sutures  (Figs.  238  and  239) ;  5. 
Superficial  integumentary  sutures. 


line  from  the  edge,  down  to  the 
interna,  as  in  phleborrhaphy  (Fig.. 
250),  the  apposing  borders  at  oppo- 
site points,  interruptedly  about  a  line  apart,  with  a  fine  curved  needle 
armed  with  fine  silk  or  chromicized  catgut ;  tie  each  suture,  carefully  avoid- 
ing inversion  of  the  borders  of  the  wound,  suture 
separately  the  sheath  of  the  artery,  and  close  and 
dress  the  remaining  wound  in  the  usual  manner. 
When  the  wound  exceeds  more  than  half  of  th^  cir- 
cumference of  the  vessel,  sever  it  completely  and 
repair  according  to  one  of  the  following  methods : 

Murphy's  Method  (Fig.  248). — Arm  each  end 
of  three  fine  silk  or  chromicized  catgut  sutures  with 
a  cambric  needle ;  introduce  each  suture  at  an  equal 
distance  from  the  other  through  the  outer  and  mid- 
dle coats,  near  to  the  proximal  end  of  the  vessel; 
pass  the  needles  from  within  outward  through  the 
coats  at  the  distal  end  at  points  corresponding  to 
those  of  the  proximal,  about  a  third  of  an  inch 
from  the  end  of  the  vessel;  slit  the  distal  end  Fiq.  248.— Arteriorrhaphy 
briefly,  draw  the  proximal  end  into  it  with  the  Murphy's  method.  Su- 
sutures  and  tie  in  place  by  uniting  each  end  with 
its  fellow  when  the  invagination  is  completed; 
unite  the  border  of  the  exposed  end  to  the  contiguous  wall,  also  close  the 
slit  at  the  distal  extremity  (Fig.  249).  As  will  be  noted  hereafter,  the 
16 


tures  placed,  ready  for 
closing. 


214 


OPERATIVE  SURGERY. 


methods  of  repair  of  Murphy,  of  Salomon  and  of  Bangle  in  complete  divi- 
sion of  an  artery  are  respectively  similar  to  those  of  Robson  and  Winslow, 
.^  of    Schaffe   and    Gushing,    and 

of  Poggi,  uretero-ureteral  anas- 

tomoseo    (page   854,   Vol.    II). 

In  fact,  Van  Hook's  plan  in  the 

latter  has  met  with  success  in 

the  former  operation. 

Veins  may  he  closed  (phle- 

borrhaphy),  the  same  as  arteries 

when  wounded,  by  longitudinal 

or  oblique  incisions  (Fig.  250). 

If  a  vein  be  nicked  the  opening 

is  closed  by  ligature,  as  illus- 
trated (Fig.  250)  and  expressed 

in  the  text    (page  215).     The 

continuous  suture  is  often  em- 
ployed in  sewing  wounds  in  veins. 

Ligature  of  the  middle  meningeal  artery  is  con- 
sidered in  connection  with  injuries  of  the  skull,  as  then  it  is  often  required 
(page  237). 

The  Remarks. — The  portion  of  artery  resected  ought  not  to  exceed  half 
an  inch  in  length,  except  at  flexures  of  joints  where  greater  relaxation  can 
be  secured;  traction  loops,  temporary  ligatures,  or  forceps  guarded  by  rub- 
I)er  tubing,  may  be  employed  to  control  the  circulation.  The  rat-tooth 
forceps  used  in  eye  surgery;  a  fine  cambric  needle  with  elongated  eye;  fine 
twisted  silk  the  size  of  the  needle  and  not  too  firmly  tied,  are  desiderata 
of  importance  in  these  measures. 


FtG.  249.— Arterior- 
rhaphy.  Murphy's 
method.  Union 
completed. 


Fig.  250.— Phleborrhaphy, 
seen  below.  Ligaturing 
stitch,  seen  above. 


CHAPTER  V. 
OPERATIONS  ON  VEINS,   CAPILLARIES,  ETC. 

Veins  and  capillaries  often  require  vigorous  treatment,  not  only  for  the 
purpose  of  arresting  hremorrhage,  but  also  to  remedy  the  troublesome  and 
distressing  symptoms  and  the  unsightly  deformities  that  arise  from  unusual 
development  incident  to  obstructed  circulation  and  telangiectatic  growth. 
Veins  are  ligatured  principally  to  arrest  hemorrhage  and  cure  phlebectasy. 

The  Ligature  of  Veins. — Veins,  like  arteries,  may  be  ligatured  in  their 
continuity  or  at  their  divided  extremities.  Large  venous  branches,  when 
divided  in  the  course  of  an  operation,  should  be  tied,  otherwise  they  may 
give  rise  to  an  objectionable  amount  of  bleeding,  which  will  hinder  the 
operator,  interfere  with  the  rapidity  of  union,  and  possibly  require  reopening 
of  the  wound  to  arrest  haemorrhage.  If  a  large  vein — as  the  internal  jugular, 
the  femoral,  etc. — be  nicked  during  an  operation,  a  ligature  may  be  thrown 
around  it,  above  and  below  the  opening,  or  the  nicked  portion  only  may  be 
sewed  or  tied.  Tying  the  opening  exposes  the  patient  to  greater  danger  of 
(Fig.  250)  hasmorrhage  than  does  sewing,  especially  if  the  catgut  ligature 
be  applied.  A  fine,  firm  silk  ligature  is  better  for  this  purpose,  as  it  can  be 
more  securely  tied.  The  practice  of  sewing  the  divided  borders  with  fine 
catgut,  is  highly  extolled  by  many  writers.  The  application  to  a  cut  in  a 
vein  of  a  ligature  is  followed  quite  surely  by  thrombosis  and  closure  of  the 
vessel.  The  repair  by  suture  in  the  manner  of  intestinal  sewdng  is  not  often 
followed  by  a  similar  result.  If  it  be  determined  to  tie  the  vessel,  it  should 
be  done  above  and  below  the  w^ound,  otherwise  troublesome  haemorrhage  may 
follow.  In  the  instance  of  complete  ligature  of  the  femoral  vein,  it  is 
advised  that  the  femoral  artery  be  not  ligatured  at  the  same  time. 

The  Results. — In  fifty-one  cases  of  ligature  of  the  internal  jugular,  six 
died  of  secondary  haemorrhage,  the  result  of  infection.  With  complete 
asepsis  but  little  danger  attends  the  procedure. 

According  to  Braun,  death  from  secondary  haemorrhage  followed  lateral 
ligature  of  the  internal  jugular  in  three  of  twelve  cases.  In  one  case  each 
of  the  external  jugular  and  subclavian  veins  and  in  five  of  the  axillary  all  re- 
covered. In  eight  of  lateral  ligature  of  the  femoral,  six  died — five  caused  by 
pyaemia.  Simultaneous  ligature  of  the  femoral  vessels  in  twenty-four  cases 
was  followed  by  gangrene  of  the  limb  in  fourteen.  In  twenty-five  instances 
of  ligature  of  the  vein  alone  gangrene  did  not  occur. 

Operations  for  Varicose  Veins. — When  the  veins  of  the  lower  extremities 
and  elsew^iere  become  too  much  distended  to  be  amenable  to  palliative  meas- 
ures, it  is  often  advisable  to  resort  to  operative  interference,  with  the  view  of 

215 


216  OPERATIVE  SURGERY. 

occluding  the  distended  canals.  Injection,  acupressure,  ligaturing,  and  ex- 
cision are  the  common  means  employed  for  this  purpose. 

Injection. — The  vein  is  compressed  at  points  an  inch  or  less  above  and 
below  the  seat  of  operation  with  the  fingers,  or  by  small  pads  confined  in 
position  with  adhesive  plaster.  The  latter  plan  is  the  better.  Before  the 
injection  is  introduced  the  selected  portion  of  the  vein  is  emptied  by  diver- 
gent pressure  of  the  fingers  upon  the  vessel,  after  which  it  is  allowed  to  fill 
again.  The  emptied  portion  is  allowed  to  fill  from  below — not  from  a  col- 
lateral branch — and  then  the  operation  is  completed  by  injecting  slowly 
into  the  isolated  portion  twenty  or  thirty  drops  of  a  twenty-per-cent  solution 
of  subsulphate  of  iron  and  water.  Almost  immediately  the  contents  of  the 
vessel  become  coagulated,  when  the  limiting  pressure  can  be  removed.  The 
patient  should  be  kept  quiet  for  a  few  days,  and  any  tendency  to  undue  in- 
flammation combated.  It  is  wise  to  remember  that  portions  of  the  vein  hav- 
ing collateral  branches  should  not  be  injected  for  fear  of  embolism.  This 
method  is  rarely  employed. 

The  Results. — Of  the  one  hundred  and  three  cases  some  time  since 
reported,  seventy-nine  were  cured,  one  died,  and  of  the  remainder,  sixteen 
were  failures. 

Acupressure. — Acupressure  is  applied  here  in  substantially  the  same  man- 
ner as  for  arresting  the  circulation  of  arterial  trunks  (page  75).  Thoroughly 
purified  needles  or  pins,  which  may  or  may  not  have  been  constructed  for 
the  purpose,  are  carried  beneath  the  vein  at  intervals  of  an  inch  or  so,  and 
caused  to  compress  the  superimposed  tissues  by  means  of  carbolized  silk  or 
cotton  yarn  wound  over  their  protruding  ends.  The  pins  are  removed  on 
the  sixth  or  seventh  day,  depending  on  the  degree  of  ulceration  produced. 
Caution  should  be  observed  that  the  pins  be  not  passed  through  instead  of 
beneath  the  vein,  or  a  serious  phlebitis  may  follow. 

Subcutaneous  Ligaturmg. — Subcutaneous  ligaturing  is  employed  less  now 
than  formerly.  It  is  best  applied  to  veins  of  the  lower  extremities,  and  the 
use  should  be  supplemented  with  vigorous  antiseptic  measures.  The  location 
of  the  veins  can  be  indicated  by  marking  the  integument  over  them  with 
iodine,  while  they  are  fully  distended  by  upright  posture,  or  by  obstruction 
of  the  return  circulation  with  the  patient  in  the  recumbent  position.  The 
latter  method  is  the  better,  because  it  brings  the  vessels  more  directly  under 
command  and  reduces  the  liability  of  their  puncture  or  the  involvement  of 
contiguous  important  structures  to  a  minimum. 

The  Operation. — Pass  a  common  straight  or  curved  sterilized  needle, 
armed  with  a  catgut  ligature,  beneath  the  vein,  through  the  skin,  causing 
it  to  emerge  at  the  opposite  side  of  the  vessel,  then  re-enter  the  needle  at 
the  point  of  emergence,  pass  it  in  front  of  the  vein,  after  which  the  direc- 
tion is  changed  so  as  to  carry  it  in  front  of  the  vessel  and  out  at  the  point 
of  entrance.  The  ligature  is  tied,  cut  short,  and  the  wound  treated  antisep- 
tically.  Often  these  ligatures  are  applied  at  intervals  of  an  inch  or  so  the 
entire  length  of  the  dilated  vessel.  The  limb  is  then  surrounded  with  anti- 
septic dressing,  elevated  somewhat,  and  the  patient  kept  in  bed  for  a  week 
or  ten  days,  and  longer  if  indications  demand  it.     If  the  blood  in  the  inter- 


OPERATIONS  ON  VEINS,   CAPILLARIES,   ETC.  217 

veiling  spaces  becomes  necrosed,  giving  rise  to  fluctuation,  it  should  l)e 
evacuated.  If  ligature  abscesses  appear,  the  offending  ligatures  should  be 
removed  and  the  suppurating  foci  kept  well  cleansed.  A  special  straight  or 
curved  unthreaded  needle,  with  an  eye  at  the  end  provided  with  a  handle, 
is  admirably  fitted  for  this  purpose  (Fig.  251).   The  needle  is  threaded  after 


Pig.  251. — Keyes'  needle  for  treatment  of  varicocele. 

the  passage,  behind  and  in  front  of  the  vessel  respectively,  and  the  ligature 
placed  by  its  withdrawal  in  each  instance;  thus  a  prompter  and  better  ap- 
plication of  the  ligature  is  secured  than  by  the  former  implement. 

The  Precautions. — In  the  subcutaneous  ligaturing  of  veins,  as  the  long 
and  short  saphenous,  the  accompanying  nerves  may  be  accidentally  included 
in  the  ligature.  However,  if  the  vein  be  drawn  forward  (Fig.  200,  e,  f)  away 
from  the  nerve  and  the  needle  passed  as  closely  as  possible  to  the  vessel,  but 
little  trouble  will  result  from  their  association.  In  many  instances  it  is  diffi- 
cult to  properly  outline  the  dilated  vessels,  owing  to  their  depth  and  tortuous 
course,  and  in  such  cases  the  passage  of  the  needle  is  followed  by  brisk 
haemorrhage,  notwithstanding  the  great  caution  exercised  in  the  insertion. 
The  lack  of  surgical  precision  in  the  application  of  the  ligature,  the  fre- 
quency of  stitch-hole  abscess  and  increased  temperature  following  it,  are 
strong  objections  to  the  method,  as  they  suggest  the  possibility  of  phlebitis 
and  thrombotic  infection — complications  that  are  reported  to  have  ensued 
and  been  followed  by  death  from  pyaemia  in  rare  instances. 

The  Results. — As  yet  there  is  no  good  reason  known  to  us  to  regard  this 
method  as  less  annoying  or  more  effective  than  treatment  by  excision. 

Incision  and  ligaturing  {excision)  is  a  wise  plan  of  treatment  in  all  in- 
stances, more  especially  in  those  cases  where  the  veins  are  tortuous  or  ill  de- 
fined. The  dilated  vessels  are  exposed  by  incision  along  the  course  of  greatest 
tortuosity,  tied  above  and  below,  excised,  and  the  wound  closed  in  the  usual 
manner.  Many  authorities  advise  excision  as  preferable  to  any  other  method 
of  treatment.  The  writer  has  simultaneously  tested  on  several  occasions,  as 
far  as  possible,  the  comparative  worth  of  this  and  the  preceding  method  on 
the  same  patient.  The  recovery  was  prompter,  the  pain  and  annoyance  less 
in  the  limb  subjected  to  the  latter  method  in  every  instance.  The  final  re- 
sult can  not  yet  be  estimated. 

The  ligature  of  the  internal  saphenous  vein  (Trendelenburg),  near  to  the 
saphenous  opening,  is  advised  for  the  cure  of  varices  involving  the  branches 
of  this  vessel.  Ligaturing  the  vessel  relieves  it  of  the  pressure  of  the  column 
of  blood  below  the  point  of  tying,  and  thereby  permits  the  restoration  of  vas- 
cular tone.  Four  or  five  inches  of  the  vein  may  be  removed,  carefully 
tying  the  collateral  branches.  If  this  method  fail,  extirpation  or  multiple 
ligature  of  the  veins  of  the  leg  may  be  done.  As  in  all  operations  on 
veins,  strict  asepsis  should  be  practiced.  The  wound  is  closed,  the  extrem- 
ity wrapped  in  cotton,  snugly  l)andaged,  and  immolnlized  for  ten  days. 
The  fact,  as  reported,  that  pad  pressure  on  the  saphenous  vein  (Landerer) 


218 


OPERATIVE  SURGERY. 


cures  the  discomfort  in  ninety  per  cent  of  the  cases  emphasizes  the  impor- 
tance of  ligaturing  the  vessel.  In  the  experience  of  the  author  this  method 
is  unreliable  in  those  cases  with  free  communication  between  the  superficial 
varices  and  deeper  venous  circulation,  and  for  apparent  reasons.  Ferguson 
ties  the  saphenous  vein  at  two  points  near  the  femoral  and  cuts  out  a  section, 
then  makes  a  semilunar  incision  through  the  skin,  from  the  lower  part  of 
the  thigh  along  the  inner  side  of  the  leg,  forming  a  flap  which  overlies  the 
varicosities.  The  incision  is  deepened,  the  vessels  severed  and  tied,  the  flap 
turned  over,  the  normal  and  abnormal  veins  and  their  branches  dissected  away, 
the  flap  restored,  borders  united,  the  limb  dressed  and  confined  as  before. 

Schede  makes  a  circular  incision  around  the  leg  down  to  the  veins,  which 
he  exposes  for  a  distance  above  and  below  by  means  of  circular  flaps.  The 
vessels  are  tied  between  two  ligatures,  the  portions  excised,  the  flaps  replaced, 
borders  united,  and  limb  dressed  and  confined  as  usual.  The  long  and 
short  saphenous  nerves  should  not  be  divided,  if  possible  to  avoid  them. 

Venesection. — Although  venesection  can  hardly  be  classed  as  an  operation 
of  much  moment,  in  a  surgical  sense,  yet  the  infrequency  of  its  employment 
at  the  present  time  is  apt  to  render  a  knowledge  of  the  details  connected 
therewith  somewhat  uncertain  in  the  minds  of  a  majority  of  the  practitioners 
of  the  present  generation.  The  veins  selected  for  the  procedure  are  the  in- 
ternal saphenous  at  the  ankle, 
the  median  basilic,  or  median 
cephalic  at  the  bend  of  the 
elbow,  and  the  external  jugu- 
lar vein.  The  instruments  re- 
quired for  the  purpose  is  the 
ordinary  thumb  lancet,  or  a 
curved  or  straight  sharp-pointed 
bistoury.  The  first,  however, 
possesses  the  greatest  number 
of  traditional  virtues.  If  the 
region  of  the  elbow  be  selected, 
the  median  cephalic  vein  is  pre- 
ferred, on  account  of  its  greater 
distance  from  the  brachial  ar- 
tery and  the  posterior  relation 
to  cutaneous  nerves.  The  arm 
should  be  constricted  by  a  band- 
age drawn  sufficiently  tight  to 
obstruct  venous  return  without 
interfering  with  arterial  circu- 
lation ;  this  will  cause  the  veins 
to  appear  prominently  distend- 
ed, unless  the  patient  be  very 
fleshy,  in  which  case  the  sense  of  touch  must  be  relied  on  to  indicate  the 
exact  situation  of  the  vessel.  The  vein  should  be  well  defined  by  the  finger, 
and  held  in  position  by  the  thumb  or  finger  placed  just  below  the  point  of 


Fig.  252. — Opening  the  vein  with  scalpel. 


OPERATIONS  ON  VEINS,  CAPILLARIES,  ETC. 


219 


incision.  After  thorough  cleansing,  the  incision  is  made  oliliquely  to  the 
transverse  diameter  of  the  vein,  and  of  sufficient  dejotli  to  freely  open  the 
vessel  without  severing  it  (Fig.  252).  The  flow  of  blood  may  be  increased 
by  causing  the  patient  to  grasp  firmly  a  stick  or  broom  handle;  it  may  be 
impeded  by  the  interposition  of  the  subcutaneous  fat,  which  should  be 
pushed  aside.  The  amount  of  blood  taken  will  be  regulated  by  the  strength 
of  the  patient,  whether  he  be  standing  or  lying,  and  by  the  demands  for  de- 
pletion. If  standing  or  sitting,  the  effects  will  be  sooner  felt  than  if  in  a 
recumbent  posture.  Usually,  however,  from  half  a  pint  to  a  pint  will  suffice. 
The  flow  is  arrested  by  removing  the  bandage  above  and  applying  the  finger 
to  the  bleeding  point,  after  which  a  small  aseptic  compress  is  placed  over 
the  incision,  and  confined  in  position  by  adhesive  plaster  so  arranged  as  not 
to  impede  the  venous  return. 


i.  .  .  . 

Fig.  253. — Instruments  employed  in  the  operation  of  infusion. 
a.  Scalpel,  b.  Thumb  forceps,  c.  Scissors,  d.  Aneurism  needle,  e.  Ordinary  dropper 
with  curved  point,  extemporaneous  cannula.  /.  Toothpick  for  same  purpose,  g. 
Cooper's  cannula,  h.  Kelly's  needle,  i.  Luckett's  cannula.  J.  Fowler's  cannula. 
m.  Harris's  cannula,  n.  Fowler's  thermometer  for  cannula,  o.  Catgut  and  silk 
wormgut.    p.  Needles. 


//  the  external  jugular  vein  be  selected,  the  compress  is  placed  just  above 
the  clavicle,  and  confined  in  position  by  a  bandage  carried  under  the  oppo- 
site axilla.  The  pressure  is  then  applied  to  the  vessel  ahove  the  point  of 
proposed  incision,  and  the  vessel  is  opened  at  a  right  angle  with  the  fibers  of 
the  platysma  myoides  muscle.  The  finger  must  always  be  placed  on  the 
incision  before  the  compress  is  removed,  in  order  to  prevent  the  entrance  of 
air  into  the  circulation. 


220 


OPERATIVE  SURGERY. 


Transfusion. — Transfusion  is  a  means  employed  to  overeome  the  exhaus- 
tion caused  by  disease  and  shock  from  the  loss  of  blood.  In  the  latter,  how- 
ever, it  is  of  the  greatest  practical  utility.  Blood,  defibrinated  blood,  and 
saline  solutions  (infusion)  are  employed  to  meet  the  demands.  The  employ- 
ment of  saline  solutions  has,  however,  superseded  entirely  the  use  of  blood. 

The  fluid  may  be  introduced  into  an  artery  or  a  vein,  either  of  which 
may  be  chosen  at  a  part  distant  from  the  wound,  causing  the  need  for  in- 
fusion, or  at  the  wound  itself,  in  tbe  latter  instance  possibly  utilizing  for 
the  purpose  a  vessel  already  exposed.  The  former  course  is  the  better,  and 
commonly  the  bend  of  the  elbow  is  well  adapted  for  the  requirement.  The 
fluid  especially  employed  is  composed  of  six  parts  of  pure  table  salt  to  one 
thousand  of  boiled  filtered  water,  practically  a  heaped  teaspoonful  of  the 
former  to  a  quart  of  the  latter.  Special  fluids  are  commended  by  some 
because  of  their  closer  approach  to  the  composition  of  the  blood  serum. 
However,  these  special  fluids  appear  to  be  of  insufficient  practical  impor- 
tance to  militate  against  the  use  of  the  simpler  fluids  on  all  occasions. 
Various  apparatus  are  employed  for  the  purpose  of  infusion.  Some  are 
simple,  others  of  a  complicated  nature.  The  simpler  and  the  handier  the 
means,  the  better  for  the  prompt  and  full  measure  of  benefit. 


Fig.  354. — Apparatus  for  infusion. 

Ordinary  fountain  syringe.     Kelly's  apparatus.     Graduated  glass  reservoir  and  infusion 

tube.    Fowlers  apparatus  with  thermometer  attachment. 


The  Operation  of  Infusion  (Venous). — Cleanse  the  field  of  operation 
thoroughly;  constrict  the  arm  three  or  four  inches  above  the  elbow  joint 
(Fig.  252)  with  a  rubber  cord  or  a  bandage;  choose  the  most  prominent 
vein,  usually  the  median  basilic  (Fig.  252)  ;  make  an  incision  down  upon 
the  vein  in  the  long  axis,  of  proper  length  to  freely  expose  it ;  separate  the 
vessel  from  the  contiguous  tissues  with  a  probe,  a  grooved  director,  or  an 
aneurism  needle ;  ligature  the  vein  at  the  lower  aspect  of  the  wound ;  pass  a 
second  ligature  an  inch  or  so  above  the  preceding  one,  leaving  it  untied; 
divide  the  vein  between  the  ligatures,  transversely  upward,  through  half  of 


OPERATIONS   ON   VEINS,   CAPILLARIES,   ETC. 


221 


the  circumference,  with  scissors  (Fig.  255)  ;  insert  the  end  of  the  cannuha 
(the  solution  slowly  escaping  from  it)  upward  into  the  vein  and  tie  it  in 
place  with  the  second  ligature,  making  a  bow-knot ;  remove  the  constriction 
above,  and  introduce  the  fluid  slowly  at  the  proper  temperature  (118°  F. 
to  120°  F.),  carefully  watching  the  effect  on  the  vein  above  the  incision; 
divide  the  vessel  between  the  /M     ligatures  after  completion,  and 

close  the  external  wound  by  fm      sewing,  and  dress  it  aseptically. 

The     Precautions.  —  Se-  Jm       cure  complete  asepsis.     Be  cer- 

tain that  salt  is  introduced,  fiv       as   the   infusion   of   water   only 

will  cause  death.     Immerse  J^F        the  apparatus  in  hot  water  be- 

fore using,  to  maintain  the        jfff         proper  temperature  of  the  fluid 

while  entering  the 
vessel.       Be     sure 

|Mf  F^W^^'Sfc.  ^^^^     ^■'^^     proper 

'*"  '^^jr^'^^^p  temperature    is 

maintained     by 
constant    scrutiny.     Insert    the    tube 
while  fluid  is  escaping,  to  avoid  the  in- 
troduction of  air.     The  observance  of 
'iM         these  precautions  may  obviate  the  oc- 
'm  currence  of  chills  at  the  time  of  opera- 

§W  tion.      A  blunt,  not   a   sharp   cannula 

should   be    introduced,    for   the   latter 
may  puncture  the  vessel  and  otherwise 
-  ^'1^  hinder   prompt   action.      Avoid   leaky, 

<^Jl'*^^*%^^"~^:^  ^       ^        defective  apparatus.     The  amount  in- 
'Cy         ^        fused  should  depend  on  the  case  and 
the  effect  on  the  patient,  from  a  pint 
Yio.  255.  to  a  quart,  introduced  during  half  to 

Introducing  the  tube  in  infusion.         three  quarters  of  an  hour,  ceasing  at 

once  with  unfavorable  signs.  Embar- 
rassment of  the  action  of  the  heart  and  oedema  of  the  lungs  or  brain  may 
follow  a  too  free  introduction  of  the  fluid.  Filtration  can  be  rapidly  done 
by  passing  the  fluid  through  sterilized  absorbent  cotton  surrounded  with 
sterile  gauze. 

Injection  of  Saline  Solutions. — The  introduction  into  the  veins  or  the 
arteries  of  various   saline  solutions,  the  chief  ingredients  of  which  are 
common  salt  and  carbonate  of  soda,  is  highly  recommended. 
Szumann  recommended  the  following: 

I^  Water,    sterilized 32  ounces ; 

Common  salt 1^  drachm ; 

Carbonate  of  soda 15  grains. 

M.     Heat  to  110°  or  112°  F. 

Dawharn's  prompt  method  of  practicing  saline  transfusion  by  "nee- 
dling "  may  be  serviceable.  The  saline  solution  is  quickly  prepared  by  add- 
ing a  heaped  teaspoonful  of  table  salt  to  a  quart  of  warm  boiled  water.    The 


222 


OPERATIVE  SURGERY. 


method  requires  "an  ordinary  Davidson's  syringe,  an  ordinary  soft-rubber 
catheter,  or  a  small  rubber  drainage  tube  and  an  ordinary  hypodermic 
needle — large  size  preferred,  though 
this  is  not  essential.  After  thorough 
aseptic  preparation,  the  needle  is 
,  pushed  slowly  into  the  radial,  poste- 
rior tibial,  or  femoral  artery  until 
arterial  blood  appears  at  the  outer 
extremity,  the  catheter  is  then  slipped 
over  the  base  of 
the  needle  and 
tied,  the  noz- 
zle of  the  syr- 
inge is  insert- 
ed into  the  eye 
of  the  cath- 
eter, the  needle  is  held  firmly  in  place,  and  the  fluid 
is  pumped  slowly  and  cautiously  into  the  arterial  cur- 
rent. A  fountain  syringe  elevated  six  feet  will  an- 
swer the  purpose  equally  well.  A  pint  of  this  fluid  can  be  thus  introduced 
within  half  an  hour.  If  the  shock  from  loss  of  blood  be  profound,  it  is 
advised  that  the  fluid  be  as  hot  as  the  hand  can  well  bear  (118°  F.).  In 
any  event  the  temperature  of  the  fluid  should  be  not  less  than  110°  F. 

The  Fallacies. — The  needle  may  not  enter  the  vessel,  or  it  may  be  uncon- 
sciously withdrawn  from  it.  Under  either  of  these  conditions  the  injected 
fluid  will  cause  distention  of  the  connective  tissues  adjacent  to  the  point  of 
puncture.  If  the  salt  be  omitted,  the  effect  of  the  water  on  the  blood  cor- 
puscles will  quickly  kill  the  patient.  If  minute  foreign  bodies  be  present  in 
the  fluid,  the  needle  may  become  obstructed;  therefore,  the  fluid  should  be 
strained  before  it  is  used.  The  introduction  of  air  into  the  circulation  will 
not  happen  with  the  use  of  a  fountain  syringe,  but  care  should  be  taken 
or  air  will  be  introduced  with  the  use  of  Davidson's,  especially  if  the  valves 
be  defective;  then  the  instrument  should  be  immersed  in  a  saline  solution 
while  in  operation.  The  saline  fluid  will  become  cooled  before  it  is  en- 
tirely used,  unless  the  vessel  containing  it  be  placed  in  another  filled  with 
fluid  kept  still  hotter  than  this  by  frequent  additions  of  boiling  water. 

Subcutaneous  injection  of  saline  fluid  (Hypodermoelysis)  is  done  inde- 
pendently of  the  preceding  method  of  use,  and  supplemental  to  it.  A  pint 
or  two  in  divided  portions  can  be  injected  at  different  situations  into  the 
connective  tissue  of  the  thighs  or  ilio-lumbar  region  beneath  the  female 
breasts  (Kelly),  aided  by  rubbing  to  disperse  the  fluid,  for  the  purpose  of 
relieving  shock.  If  time  will  permit,  only  sterilized  fluids  should  be  em- 
ployed and  antiseptic  methods  practiced  in  other  respects. 

Copious  enemata  (Enteroclysis)  of  hot  saline  fluid,  carried  high  up  into 
the  large  intestine  by  means  of  a  tube,  are  now  employed  frequently  in  cases 
of  shock  from  loss  of  blood  of  a  lesser  degree  than  that  calling  for  its  injec- 
tion into  the  tissues  afid  vessels.    Instrumental  outfits  for  the  employment 


OPERATIONS  ON   VEINS,  CAPILLARIES,   ETC.  223 

of  enteroclysis  to  meet  the  various  indications  referable  to  disease  of  the 
kidneys  and  other  morbid  conditions  now  find  ready  and  serviceable  use, 
and  can  be  procured  at  the  shops  for  the  sale  of  instrumental  supplies. 

Arterial  infusion  has  been  advocated  on  the  basis  that  it  conveys  the 
fluid  more  equably  to  the  heart,  and  therefore  with  less  danger  of  exciting 
undue  disturbance  of  the  circulation.  The  admission  of  a  small  amount  of 
air  does  no  great  harm,  and  the  danger  of  phlebitis  is  avoided.  The  vessel 
selected  should  be  the  radial  at  the  wrist  or  the  posterior  tibial  at  the  ankle, 
either  one  of  which  is  exposed,  and  three  ligatures  are  placed  around  it  at  a 
little  distance  apart;  the  distal  one  is  tied,  and  the  proximal  one  tightened 
sufficiently  to  interrupt  the  circulation  in  the  vessel.  The  vessel  is  now 
opened  and  the  tube  inserted  and  tied  in  position  by  the  third  or  middle 
ligature,  then  the  proximal  one  is  loosened  and  the  fluid  injected  into  the 
circulation.  It  is  better  to  inject  the  fluid  against  than  with  the  natural 
flow  of  the  blood  current,  to  avoid  over-distention  of  the  capillaries.  As 
soon  as  the  injection  of  the  fluid  is  completed  the  proximal  ligature  is  tied, 
and  the  intervening  portion  of  the  vessel  removed  along  with  the  tube. 
Arterial  infusion  is  practiced  much  less  often  than  venous.  Permanent 
dilatation  of  the  walls  of  the  artery,  and  even  sloughing  of  the  soft  parts, 
have  followed  the  practice.  Kelly  no  longer  employs  it  in  females,  but 
advises  submammary  infusion  instead. 

Operations  on  the  Capillaries. — The  capillary  system  of  vessels,  like  the 
venous,  may  undergo  dilatation  of  sufficient  degree  to  create  distinct  but 
slowly  developing  and  painless  deformities  and  tumors.  The  morbid  process 
is  limited  usually  entirely  to  the  capillaries  of  the  integument;  however, 
the  deeper  and  larger  vessels  are  not  infrequently  involved  also,  not  only  at 
the  beginning,  but  during  the  development  of  the  growth.  These  growths 
vary  in  situation,  size,  shape,  and  color.  The  simplest  variety  is  known  as 
the  "  mother's  mark,"  "  birthmark,"  etc. 

A  lirthmarh  can  be  treated  by  pressure,  caustics,  hot  needles,  vaccina- 
tion, and  galvano-cautery,  depending  upon  its  size  and  situation  and  the 
fancy  of  the  operator.  It  is  not  well  to  interfere  at  all  in  early  life  except  by 
simple  means,  unless  the  growth  increases  rapidly  in  size.  The  majority  of 
these  growths  will  disappear  of  themselves  before  their  presence  becomes  a 
source  of  annoyance  or  regret  to  the  possessor.  There  are,  however,  sev- 
eral means  which  will  often  hasten  their  departure — as  the  use  of  simple 
compresses,  repeated  application  of  collodion,  or  vaccination  if  the  birth- 
mark be  located  suitably  for  the  act.  The  following  method,  introduced  by 
Dr.  Squire,  which  seemed  likely  at  one  time  to  meet  the  desired  end  in  the 
great  majority  of  cases,  can  be  employed : 

The  "  mark  "  is  frozen  with  an  ether  spray,  and  numerous  superficial 
parallel  incisions  are  made  about  one  sixteenth  of  an  inch  apart,  and  the 
whole  is  covered  with  blotting  paper,  which  is  pressed  upon  with  sufficient 
force  to  prevent  any  gaping  of  the  cuts  or  ha?morrhage;  after  fifteen  or 
twenty  minutes  the  paper  is  thoroughly  wet  with  water  and  removed.  Some- 
times a  thin  underlying  clot  of  blood  will  be  found;  this  must  be  washed 
away  carefully  with  water  aided  by  a  soft  brush,  and  the  part  dressed  asep- 


224  OPERATIVE  SURGERY. 

tically.  When  it  is  necessary  to  repeat  the  operation  the  incisions  should 
be  made  at  right  angles  to  the  previous  ones.  In  simple  cases  and  with 
proper  care  a  perfect  cure  is  secured  by  this  method,  without  scarring. 

The  injection  of  ergot,  the  solution  of  subsulphate  of  iron,  and  undiluted 
carbolic  acid,  etc.,  has  been  recommended.  They  are,  however,  uncertain 
in  their  action,  and  are  liable  to  be  followed  by  inflammation,  ulceration,  and 
sometimes  by  embolism.  The  solutions  can  be  injected  by  the  ordinary 
hypodermic  syringe,  three  or  four  drops  at  a  time,  in  various  portions  of  the 
growth.  This  method  can  not  be  commended.  The  use  of  red  heat  around 
the  base  and  over  the  surface  of  the  growth  by  means  of  the  Paquelin  cau- 
tery is  an  admirable  method,  provided  the  growth  involves  the  skin  alone  or 
only  the  capillaries  in  the  tissue  immediately  beneath  it.  If  vigorously 
applied  it  is  usually  followed  by  more  or  less  disfigurement,  depending,  of 
course,  upon  the  degree  and  extent  of  the  cauterization. 

Needles  heated  to  a  marhed  degree  of  redness,  either  by  electricity  (see 
Fig.  109)  or  the  ordinary  means,  are  admirable  agents  of  cure  in  pronounced 
cases.  They  are  thrust  into  the  vascular  growths  and  allowed  to  remain 
until  the  tissues  and  fluids  adjacent  to  them  are  cooked,  after  which  they 
are  carefully  withdrawn  and  inserted  as  before  at  another  part  of  the 
growth.  The  number  of  insertions  is  controlled  by  the  size,  vascularity,  and 
situation  of  the  abnormality.  Usually  five  or  six  introductions  will  suffice, 
and  these  should  be  made  at  the  border  rather  than  at  the  center  of  the 
growth,  the  idea  being  to  establish  a  cure  by  gradual  encroachment  from  the 
border  rather  than  by  direct  attack.  Electrolysis  often  secures  favorable 
results. 

The  Comments. — Needles  heated  by  electricity  are  the  best  agents  of 
treatment.  A  needle  should  be  introduced  and  removed  slowly  and  cau- 
tiously, as  a  rapid  introduction  will  bend  and  destroy  it.  A  rapid  removal 
will  often  cause  unnecessary  haemorrhage  on  account  of  the  adherence  to  the 
needle  of  the  cooked  tissues  that  environ  the  point  of  puncture.  The  pa- 
tient should  be  kept  quiet  for  a  few  days  after  the  employment  of  galvano- 
puncture,  and  the  seat  of  the  operation  should  be  treated  antiseptically. 

Subcutaneous  Ligaturing. — If  the  nasvus  be  of  large  size,  persistent,  of  a 
dark  color,  and  markedly  elevated,  it  may  be  suitably  treated  by  the  employ- 
ment of  subcutaneous  ligature.  Subcutaneous  ligaturing  may  be  performed 
in  several  ways,  depending  on  the  size  and  shape  of  the  tumor  and  the  fancy 
of  the  operator.    Treatment  by  ligature  is  inferior  to  that  by  needles. 

Fig.  257  represents  a  simple  method.  In  this  the  needle,  armed  with  a 
strong,  well-carbolized  silk  or  catgut  ligature,  is  thrust  beneath  the  integu- 
ment at  the  base  of  the  tumor  and  carried  subcutaneously  as  far  as  possible 
around  the  base,  and  then  passed  out  through  the  integument,  to  be  again  in- 
troduced at  the  point  of  exit  and  carried  still  farther  around  and  pushed 
through  as  before,  and  so  on  until  the  needle  is  caused  to  emerge  at  the  point 
of  primary  insertion.  The  ends  of  the  ligature  are  then  tied  in  a  firm,  hard 
knot. 

Fig.  258  represents  a  double  ligature  carried  through  the  base  of  the 
growth  and  divided;  each  portion  of  the  ligature  is  then  carried  subcuta- 


OPERATIONS  ON  VEINS,  CAPILLARIES,  ETC. 


225 


neously  around  half  of  the  l^asc  and  tied  independently  of  the  other  part. 
This  method  of  procedure  is  applicable  to  growths  having  large  bases.  Fig. 
259  represents  the  application  of  the  ligature  to  quarter  sections  of  the 


Pig.  257. 
By  a  single  ligature. 


Fig.  258. 
By  a  double  ligature. 


Fig.  259. 
Ligation  in  quarter  sections. 


base.  It  is  employed  in  still  larger  growths.  Pass  a  doul)le  ligature  through 
the  center  of  the  base,  cut  the  loop  near  the  middle,  leaving  one  end  of  the 
divided  thread  in  the  eye  of  the  needle ;  then,  after  threading  the  needle  he- 
sides  with  the  other  end  emerging  at  the  opposite  side  which  corresponds  to 
that  portion  of  the  ligature  which  was  liberated  by  the  division  of  the  loop 
(Fig.  260),  pass  it  through  the  base  at  right  angles  to  the  primary  course. 
Before  tightening  the  ligature  the  integument  in  the  course  of  constric- 
tion should  be  deeply  incised,  not  only  for  the  purpose  of  avoiding  the  pain 
and  ulceration  incident  to  the  pressure,  but  also  to  allow  the  proper  adjust- 
ment of  the  constricting  agents  (Fig.  261).  It  will  simplify  the  discrimi- 
nating and  tying  of  the  extremities  if  one  half  the  ligature  be  colored  before 
the  primary  introduction.  Fig.  262  represents  the  ligation  of  a  growth  with 
an  elongated  base.  In  this  instance  a  double  colored  ligature  is  required, 
which  is  passed  through  the  base  from  side  to  side,  commencing  and  ter- 
minating just  outside  the  extreme  limits  of  the  growth;  if  the  white  loops 
be  now  divided  on  one  side  and  the  black  on  the  other,  independent  sets  of 
ligatures  will  be  formed,  which  should  be  firmly  tied  after  the  skin  falling 


Fig.  260. 

Quarter  sections,  second  step. 


Fig.  261. 
Tying  ligature. 


Fig.  262. 
Ligature  of  elongated  base. 


within  the  grasp  of  each  ligature  has  been  first  incised.  The  separation  of 
the  growth  is  hastened  by  the  use  of  a  rubber  ligature  applied  in  a  similar 
manner.  The  introduction  into  the  vascular  growth  of  threadhl'c  scions 
which  are  charged  with  a  solution  of  subsulphate  of  iron  from  time  to  time, 
and  drawn  into  the  vascular  structure  with  the  view  of  causing  coagulation 
of  the  fluid  contents,  is  advised,  and  thus  far  the  results  of  this  method  of 
treatment  justify  its  further  employment.  It  is  open  to  the  same  objection 
as  the  introduction  of  constringing  fluids  by  other  means — the  liability  of 
infection  from  the  presence  of  the  opening  in  the  integument  for  the  pas- 
sage of  the  threads. 


226  OPERATIVE  SURGERY. 

Division  and  Ligature. — Cirsoid  growth  of  the  scalp  can  be  successfully 
treated  by  making  a  free  incision  outside  and  nearly  around  it,  down  to  the 
periosteum,  leaving  that  portion  of  the  growth  that  contains  the  largest 
vessel  undisturbed  to  form  a  pedicle  to  nourish  the  flap.  The  flap  is  raised 
and  all  bleeding  points  are  tied,  after  which  it  is  kept  separated  from  its  for- 
mer bed  by  antiseptic  gauze  until  the  surfaces  granulate.  The  surfaces  are 
then  apposed  and  soon  unite,  thus  destroying  the  growth  without  loss  of 
substance.  If  the  pulsations  in  the  flap  continue  for  four  or  five  days,  the 
dilated  vessel  entering  it  should  be  tied  at  a  distance  from  the  pedicle.  The 
hgemorrhage  attending  the  operation  is  controlled  to  a  degree  during  the 
primary  operation  by  a  strong  rubber  band  passed  around  the  head,  be- 
neath which  compresses  corresponding  to  the  course  of  the  main  vessels  that 
supply  the  scalp  are  placed.  The  bleeding  can  also  be  arrested  by  direct 
pressure  against  the  underlying  bone ;  yet,  notwithstanding  these  means,  the 
loss  of  blood  may  be  quite  severe,  and  the  operation  should  not  be  attempted 
if  the  patient  be  already  exsanguinated  or  otherwise  debilitated.  Care 
should  be  taken  to  form  a  pedicle  of  sufficient  width  to  nourish  the  flap; 
from  half  an  inch  to  an  inch,  depending  on  the  size  of  the  flap,  has,  in  the 
author's  experience,  been  ample  for  the  purpose.  If  the  dressing  be  ap- 
plied too  firmly,  the  integrity  of  the  flap  will  be  endangered.  The  author 
has  practiced  this  method  in  three  cases  of  cirsoid  change  of  the  vessels  of 
the  scalp  with  prompt  and  entire  success.  In  one  instance — involvement  of 
the  occipital — the  loss  of  blood  during  the  operation  was  considerable. 

Wyeth  commends  the  injection  into  vascular  growths  of  water  varying 
from  190°  F.  to  212°  F.,  with  the  idea  of  effecting  a  cure  by  causing  coagu- 
lation of  the  contained  blood  and  the  albuminoids  of  the  tissues.  A  syringe 
with  a  metallic  barrel  having  an  adjustable  piston  and  needles  of  as- 
sorted sizes  and  lengths  are  required,  together  with  a  suitable  receptacle  for 
the  fluid  and  a  flame  to  keep  the  water  at  the  boiling-point. 

The  Operation. — Eender  the  operation  field  aseptic  and  administer  an 
anaesthetic,  insert  the  needle  in  arterial  and  venous  growths,  deeply  into 
the  tumor  and  discharge  half  a  drachm  to  a  drachm  of  the  fluid  into  its 
various  aspects,  withdrawing  the  needle  partially  and  changing  its  direc- 
tion with  each  injection  until  the  tumor  is  hardened;  inject  in  capillary 
growths  with  a  suitable  needle,  two  to  six  drops  at  a  temperature  of  190° 
F.  at  various  parts  of  the  disfigurement,  beginning  at  the  borders. 

The  Remarlcs. — Apply  pressure  around  the  border  of  the  growth  during 
injection  to  lessen  danger  of  emboli  gaining  the  circulation.  If  the  fluid 
be  too  hot  or  be  injected  in  too  large  amounts,  or  too  forcibly,  local  slough- 
ing may  follow.  The  injection  should  cease  when  slight  blanching  of  the 
skin  is  noted.  The  amount  injected  should  depend  on  the  size  of  the 
growth;  not  more  than  four  or  five  ounces  should  be  employed  at  a  treat- 
ment in  extreme  cases.  Treatment  may  be  repeated  at  intervals  of  a  week 
or  ten  days. 

The  Results. — Several  cases  are  reported  with  favorable  outcomes.  An 
instance  of  infection  is  noted.  We  are  not  disposed  as  yet  to  regard  the 
measure  as  offering  any  advantage  over  galvano-cautery. 


CHAPTER  VL 

OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


The  brain,  spinal  cord,  and  the  nerves  arising  from  the  cerebro-spinal 
axis,  together  with  their  coverings,  are  often  the  seat  of  important  surgical 
procedures  addressed  to  the  relief  of  traumatic  and  pathological  conditions 
that  not  infrequently  affect  these  tissues.  The  delicate  nature  of  the  tis- 
sues and  their  important  functions  demand  not  only  cautious  manipulation, 
but  also  the  strictest  aseptic  technique. 

Chronic  Hydrocephalus. — Tapping  the  ventricles  for  the  purpose  of  re- 
moving the  fluid  incident  to  this  disease  is  as  yet  the  only  operative  pro- 
cedure to  which  it  is  amenable.  The  tapping  is  done  with  a  small  trocar  or 
aspirating  needle,  and  often  the  needle  is  supplemented  by  the  aspirator  it- 
self. In  either  instance  the  puncturing  agent  may  be  introduced  through 
the  anterior  f ontanelle 

close  to  its  outer  bor-  --""^^ — -  ^ 

der  to  avoid  the  lon- 
gitudinal sinus,  and 
passed  perpendicular- 
ly into  the  fluid,  cau- 
tiously avoiding  the 
cerebral  lobes  when 
possible  (Fig.  263). 
If  the  fontanelle  be 
closed  the  fluid  is 
reached  through  a 
small  trephine  open- 
ing made  at  one  of 
various  situations.  In 
the  selection  of  a  site 
for  entry,  the  motor 
zone,  the  Sylvian  As- 
sure on  account  of  the 
meningeal  and  mid- 
dle  cerebral   arteries, 

and  the  sense  centers  generally,  should  be  avoided.  Also  the  dangers  of  punc- 
ture of  a  vein  lying  on  the  surface  of  the  brain  sliould  be  anticipated  by  careful 
scrutiny  of  the  part  after  opening  the  dura.  The  situation  usually  chosen  for 
tapping  is  at  a  point  one  inch  and  a  quarter  above  and  the  same  distance  be- 
hind the  external  auditory  meatus,  as  drainage  is  thus  facilitated  by  depend- 

237 


Fig.  263. — Antero  -  posterior  section  of  the  head  half  an 
inch  from  the  median  line.  R.  Fissure  of  Rolando.  /. 
Inion.  A  and  B.  (Solid)  lines  of  puncture,  the  dotted 
lines  showing  their  imaginary  continuation  to  the  fixed 
points. 


228 


OPERATIVE   SURGERY. 


ent  position  (Keen).  If  the  trephine  be  placed  a  half  inch  higher  the  lateral 
sinus  is  more  surely  avoided.  Also  a  point  an  inch  and  a  half  above  the 
meatus  is  advised  (Fig.  393,  E).  The  puncturing  agent,  after  the  dura  has 
been  incised  sufficiently  to  admit  it,  is  introduced  and  pushed  toward  the  oppo- 
site side,  the  extremity 
being  directed  toward 
a  point  two  inches  and 
a  half  above  the  oppo- 
site external  auditory 
meatus  (Keen)  until 
H/t^^p^    \        VjL)    L-Vv//  "^fV  )    ^  f  )l  ^1  TSS\        the    fluid    is    reached 

(Fig.  364).  In  the 
normal  brain  the  dis- 
tance to  the  lateral 
ventricle  is  about  two 
and  a  half  inches.  In 
the  hydrocephalic,  this 
distance  is  lessened 
proportionately  to  the 
degree  of  the  fluid  dis- 
tention. In  the  latter 
method  the  point  of 
the  needle  is  directed 
away  from  the  basal 
ganglia ;  in  the  former  it  approaches  the  ganglia  on  account  of  the  higher 
point  selected  for  the  introduction.  The  fluid  should  be  evacuated  slowly 
and  the  flow  attended  with  moderate  and  equable  pressure  on  the  cranium  by 
a  skull-cap  bandage.  If  unpleasant  manifestations  happen  during  the  with- 
drawal of  the  fluid,  the  flow  is  promptly  arrested  for  a  time,  after  which  it  is 
permitted  to  begin  again  cautiously,  or  is  stopped  entirely,  as  circumstances 
demand.  Often  the  removal  of  three  or  four  ounces  of  fluid  or  less  will 
cause  feebleness  of  the  pulSe,  contraction  of  the  pupil,  and  evidences  of 
approaching  convulsion.  The  injection  into  the  ventricles  of  a  moderate 
amount  of  an  ordinary  saline  solution  at  the  temperature  of  the  body  is 
advisable  if  alarming  evidences  of  cerebral  disturbance  arise  at  the  time  of 
operation.  The  almost  certain  reaccumulation  of  the  fluid  has  prompted 
the  employment  of  drainage  and  the  injection  into  the  distended  ventricles 
of  a  weak  solution  of  iodine,  of  Thiersch's  or  other  suitable  medicated  fluids. 
The  drainage  agents  are  introduced  at  the  time  of  the  evacuation  through 
the  canula  used  for  withdrawing  the  fluid.  Either  a  small  rubber  tube, 
wicking,  horsehair,  or  gauze  can  be  utilized  for  this  purpose.  Horsehair 
is  the  best  drainage  agent ;  it  is  not  too  stiff  and  a  portion  of  it  can  be 
withdrawn  from  time  to  time,  thus  meeting  the  demands  of  the  case,  and, 
moreover,  it  inhibits  the  escape  of  the  fluid  in  a  manner  consistent  with 
the  greatest  security  to  the  patient.  However,  the  employment  of  drain- 
age favors  additional  risk  of  infection  and  meningitis  without  materially 
adding  to  the  recovery  of  the  patient.     The  completion  of  the  operation 


Fig.  264. — The  direction  of  puncturing  agent. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  229 

is  followed  promptly  by  closure  of  the  wound,  the  application  of  aseptic 
dressings,  and  the  establishment  of  gentle  and  uniform  pressure  on  the 
skull.  Southerland  and  Cheyne  established  drainage  anteriorly  between 
the  lateral  ventricles  and  the  subdural  space  through  an  opening  made  near 
the  anterior  fontanelle  by  means  of  several  straight  pieces  of  catgut  running 
from  the  ventricle  downward  and  backward  for  two  or  three  inches  along 
the  subdural  space.*  The  cases  best  suited  for  tapping  are  those  in  which 
severe  pressure  attends  recent  simple  meningitis,  the  later  stages  of  the 
tubercular  variety,  hydrocephalus  with  inherited  syphilis  and  chronic  men- 
ingitis with  much  expansion  of  the  head,  and  cases  with  loss  of  functions, 
such  as  vision,  etc.  (Baltzie).  It  has  been  proposed  recently  to  drain  the 
ventricles  by  tapping  the  membranes  of  the  spinal  cord  (vide  page  316). 

The  Results. — The  rate  of  mortality  from  the  operation  alone  is  small 
indeed  if  aseptic  care  be  taken.  The  percentage  of  cures  is  variously  stated 
at  five,  ten,  and  even  greater  rates;  the  results  are  much  influenced  by  the 
care  taken  in  the  selection  of  cases.  Cures  need  hardly  be  expected  to  fol- 
low a  single  tapping ;  so-called  cures  are  often  transient. 

Acute  Hydrocephalus. — There  is  good  reason  to  believe  that  the  symp- 
toms of  cerebral  compression  incident  to  an  acute  collection  of  fluid  in  the 
subarachnoid  and  ventricular  spaces  dependent,  usually,  on  tubercular  men- 
ingitis, can  at  least  be  temporarily  relieved  by  drainage.  To  effect  this,  a 
small  trephine  can  be  applied  to  the  cranium  as  in  the  preceding  instance 
and  the  ventricles  evacuated  in  a  similar  manner.  If  the  fluid  be  sub- 
arachnoid a  free  opening  is  made  through  the  membranes  of  the  brain 
and  the  fluid  is  encouraged  to  flow  by  the  employment  of  aseptic  textile 
fabrics  placed  in  contact  with  the  opening  and  covered  by  a  generous  pad 
of  aseptic  gauze.  If  centrally  located,  tapping  of  the  ventricle  may  be 
advisable.    Lumbar  puncture  is  often  followed  by  excellent  results. 

The  Results. — As  yet  the  data  of  the  operation  are  insuSijcient  to  com- 
mend the  procedure  except  as  one  calculated  to  offer  temporary  though  per- 
haps trivial  relief  from  the  cerebral  compression,  thus  gaining  time  which 
may  contribute  to  final  recovery. 

Meningocele. — Meningocele  is  a  protrusion  of  the  meninges  of  the  brain 
caused  by  an  accumulation  of  hydrocephalic  fiuid  in  the  ventricles,  and  oc- 
curs, therefore,  before  closure  of  the  fontanelles.  Meningocele  occurs  more 
frequently  at  the  posterior  fontanelle  than  elsewhere.  When  at  the  sinciput 
it  is  the  most  favorably  located  for  treatment.  The  communication  be- 
tween the  protrusion  and  the  cranial  contents  may  be  large,  quite  small,  or 
be  closed  entirely,  and  upon  the  dimensions  of  this  passage  much,  indeed, 
depends,  since  the  freer  and  shorter  is  the  communication  the  greater  are 
the  dangers  of  operation,  and  consequently  the  more  guarded  should  be  the 
prognosis.  The  tumor  should  be  protected  from  irritation  at  all  times  by  a 
covering  of  cotton  wool  or  of  other  suitable  material,  to  which  may  be  added 
also  another  measure,  the  employment  of  gentle,  equable  pressure  applied  to 
the  tumor  by  means  of  suitably  adjusted  cloth  pads  and  bandages.  The  oper- 
ative measures  are  ligature,  puncture  or  tapping,  injection,  and  excision. 

*  Brit.  Med.  Jour.,  Oct.  18,  1898. 
17 


230  OPERATIVE  SURGERY. 

Ligature. — In  the  instances  of  small  openings  into  the  cranium,  the  iso- 
lation of  the  neck  of  the  sac  and  its  ligature  with  silk  or  chromicized  cat- 
gut offers  a  favorable  outlook,  as  not  infrequent  trials  have  demonstrated. 

Puncture  or  Tapping. — Puncture  or  tapping  is  employed  as  a  palliative 
measure  rather  than  with  the  hope  of  establishing  a  cure.  The  removal  of 
the  fluid  in  this  manner  often  mitigates  and  may  relieve  entirely  for  a  time 
the  unpleasant  symptoms  attendant  upon  a  rapid  development  of  the  tumor, 
thereby  prolonging  life  directly,  and  also  affording  the  surgeon  an  oppor- 
tunity to  act  with  deliberation  and  forethought  in  the  selection  of  sterner 
measures  of  relief.  The  fluid  should  be  withdrawn  slowly  and  with  strict 
aseptic  care,  to  avoid,  as  far  as  possible,  cerebral  disturbance  and  subsequent 
meningitis. 

Injection. — The  injection  of  a  drachm  or  two  of  equal  parts  of  the  com- 
pound tincture  of  iodine  and  water — or  a  similar  amount  of  the  iodoglycerin 
solution  * — can  be  safely  employed  if  all  communication  be  shut  ofl'  between 
the  tumor  and  the  cranial  cavity.  If  the  channel  be  not  occluded  already, 
or  the  lumen  easily  controlled  by  pressure  or  other  simple  means,  during  the 
process  of  injection,  this  measure  of  treatment  should  be  regarded  as  unwise 
and  not  permissible,  except  for  special  reasons.  Before  the  introduction  of 
the  curative  agent  into  the  sac  of  the  tumor  a  small  portion  of  the  fluid 
should  be  withdrawn.  The  amount  of  the  curative  fluid  introduced  should 
equal  that  withdrawn.  After  the  injection  of  the  fluid  the  patient  should 
be  kept  quiet,  and  great  care  exercised  to  prevent  the  entrance  into  the 
cranial  cavity  of  any  of  the  medicated  contents  of  the  sac. 

Excision. — Excision  of  the  tumor  with  proper  care  is  the  most  satisfactory 
method  of  cure. 

The  Operation. — The  head  and  the  tumor  should  be  shaved  and  rendered 
thoroughly  aseptic.  An  incision  is  then  made  down  to  the  dura  through 
the  scalp  and  fascise  at  the  neck  of  the  tumor,  and  so  located  as  to  admit  of 
the  formation  of  flaps  of  ample  size  and  proper  shape  to  cover  the  final 
wound.  These  flaps  are  separated  carefully  from  the  dura  and  pulled  aside. 
A  sufficient  amount  of  fluid  is  then  withdrawn  from  the  tumor  to  permit 
the  walls  of  the  neck  of  the  sac  to  be  readily  approximated  with  each  other 
on  a  line  with  the  cranial  bones.  "While  thus  held  with  a  clamp  or  the 
fingers  the  neck  of  the  sac  is  divided  cautiously  for  a  short  distance  with 
scissors,  and  the  serous  surfaces  of  the  divided  borders  are  approximated  by 
fine  silk  or  catgut  sutures  applied  in  a  continuous  overhand  manner.  The 
cutting  and  sewing  are  repeated  alternately  until  the  neck  of  the  sac  is 
finally  severed  and  the  divided  borders  of  the  membranes  are  united  com- 
pletely and  securely.  If  the  neck  of  the  sac  has  been  already  occluded,  the 
operative  measure  is  much  simplified.  The  wound  is  closed  in  the  usual 
manner  and  dressed  with  an  abundance  of  antiseptic  gauze  confined  some- 
what tightly  in  place. 

The  Precautiojis. — Carefully  distinguish  between  meningocele  and  enceph- 
alocele.    If  possible  avoid  a  too  free  escape  of  fluid  since  convulsions  and  death 

*  The  iodoglycerin  solution  is  made  by  dissolving  ten  grains  of  iodine  and  thirty 
grains  of  iodide  of  potassium  in  an  ounce  of  glycerin. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  231 

may  folloAV  as  the  result.  If  evidences  of  impending  misfortune  arise  for 
this  reason,  the  introduction  into  the  sac  of  a  small  amount  of  warm  aseptic 
saline  solution  may  give  prompt  relief.  As  meningitis  is  to  be  feared  most, 
antisepsis  before  and  after  exposure  of  tlie  membranes  is  commended. 
Drainage  should  not  be  employed  unless  bruising  or  tearing  of  the  tissues 
has  attended  the  operation. 

The  Results. — The  number  of  reported  cures  following  treatment  by  ex- 
cision encourage  continued  trial  of  the  measure  in  similar  cases,  especially 
as  no  other  method  offers  like  favorable  results. 

Encephalocele. — Encephalocele  is  located  in  like  situations  as  meningo- 
cele, and  must  be  distinguished  from  the  latter.  The  contents  of  encephalo- 
cele are  composed  of  cerebral  substance  and  dropsical  membranes  attended 
often  with  more  or  less  fluid.  The  operative  measures  are  quite  futile,  but 
in  general  are  similar  in  character  to  those  for  meningocele.  Eepeated 
puncturing  with  a  fine  needle,  followed  by  pressure  carefully  and  uniformly 
applied,  offers  the  safest  and  most  rational  method  of  practice  for  cure  of 
this  infliction. 

The  Operation  of  Craniotomy. — Craniotomy  is  a  term  commonly  applied 
to  the  opening  of  the  cranium  for  obstetrical  purposes.  It  is  used  here  to 
denote  the  opening  of  the  cranium  for  the  purpose  of  relieving  cerebral 
pressure,  of  stimulating  mental  development,  etc.  Surgically  speaking, 
craniotomy  may  be  divided  into  the  circular,  linear,  and  irregular  varieties, 
according  to  the  outline  of  the  opening  made  in  the  cranium. 

Circular  Craniotomy. — Circular  craniotomy  consists  in  making  a  cir- 
cular opening  in  the  cranium,  usually  with  a  trephine,  and  therefore  is 
called  trephining  the  cranium.  There  are  two  patterns  of  trephines  with 
similar  handles  (Fig.  265)  deserving  of  special  attention — the  crown  or 
circular  (e)  and  the  conical  or  Gait's  (c,  d).  The  latter  is  a  much  safer 
instrument,  because  as  soon  as  the  inner  table  of  the  cranium  is  sawn 
through,  the  instrument,  on  account  of  the  conical  shape  and  spiral  jDeriph- 
eral  teeth,  assumes  a  screwlike  character  and  is  arrested  in  its  track.  In  the 
case  of  the  former  pattern,  the  arrangement  of  the  teeth  is  different,  and  for 
this  reason  the  membranes  are  promptly  torn  and  the  brain  injured,  unless 
great  caution  be  exercised  in  the  use.  The  diameters  of  these  instruments 
vary  from  one  half  inch  to  two  inches  and  a  half.  Circular  craniotomy  with 
a  trephine  of  small  caliber  is  commonly  practiced  for  relief  of  depressed  frac- 
ture of  the  cranium  and  epidural  haemorrhage.  The  large  sizes  are  used  in 
operations  for  brain  tumors. 

Craniotomy  for  Fracture  of  the  Skull. — Circular  craniotomy  is  commonly 
practiced  for  this  injury.  The  field  of  operation  is  prepared  by  cutting  the 
hair  short,  scrubbing  and  disinfecting  the  scalp,  and  shaving  it  for  a  consid- 
erable distance  around  the  seat  of  the  injury.  The  patient  is  anesthetized 
if  not  completely  unconscious,  preferably  with  chloroform,  as  it  causes  less 
cerebral  excitement.  However,  the  choice  of  an  anesthetic  is  a  matter  of 
opinion.     The  head  is  conveniently  raised  and  supported  by  a  firm  pillow. 

The  Operation  of  Circular  Craniotomy  (Trephining), — With  a  scalpel 
(Fig.  265,  a)   make  an  oval  incision  of  the  scalp,  through  sound  tissue  if 


"1 


(  ' 


Fig.  265.— Instruments  used  in  craniotomy  for  fracture  of  skull. 
a.  Scalpels,    i.  Periosteotome.    c,  d,  e,  and  g.  Trephines  and  handle.    /,  a.  Gouges     ?i  i 
Grigh-Haertel  saw.    h.  Bone  elevator.    I,  m.  Bone-gnawing  forceps.    71,  p    Sequestrum 
forceps.  0.  Serre-flnes.  r.  Probe,  s.  Rawhide  mallet  {don't  boil  it),  t.  Trephine  brush. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


233 


possible,  down  to  the  pericranium  (Fig.  2G()),  of  adequate  size  to  expose  the 
fracture  and  well  suited  for  drainage.    The  crucial,  T-  or  Y-shaped  incision 
can  be  substituted  for  the  oval  if  injury  of  the  soft  parts  be  extensive,  or  the 
loss  of  blood  incident  to  the 
formation  of  the  oval  flap  be 
especially  objectionable.    The 
bleeding  can  be   quickly  ar- 
rested by  clamping  the  scalp 
at  the  seat  of  the  flow  with 
serre-fines     (Fig.     265,     o)  ; 
later  ligatures  are  applied. 

Eaise  the  periosteum  with 
a  periosteotome  (Fig.  265,  &) 
at  the  seat  of  fracture  suffi- 
ciently to  permit  the  proper 
application  of  the  trephine. 
Select  a  trephine  of  moderate 
caliber — say  one  half  to  three 
quarters  of  an  inch — push 
down  the  pin  for  about  an 
eighth  of  an  inch  below  the 
teeth  of  the  instrument;  fas- 
ten the  pin  firmly  in  position, 
and  place  the  point  on  solid 
bone  (a)  as  near  to  the  line 
of  depression  as  is  wise  (see  p. 
236,  Important  Considerations),  and  at  the  point  best  calculated  to  facilitate 
elevation  (Fig.  267),  provided  it  be  not  located  above  an  important  vessel. 

Bear  firmly  on  the 
trephine  to  intro- 
duce the  point  into 
the  bone;  turn  the 
instrument  quickly 
and  lightly  from 
right  to  left,  and 
the  reverse  until  a 
groove  is  made  in 
/    ^"--^^_JiPC     ^  ^X^~-    ^         )_^j^  I     the    bone    of    suffi- 

cient depth  to  re- 
tain the  instrument 
in  place  during  fur- 
ther action.  Dur- 
ing this  step  of  the 
operation  it  is  wise 
to  hold  the  head  of  the  trephine  in  place  with  the  thumb  and  index  finger 
of  the  disengaged  hand,  or  by  the  index  finger  of  the  other  extended  along 
the  trephine  down  to  the  skull.     When  a  suitable  track  is  made  withdraw 


Fig.  266. — Circular  craniotomy  (trephining). 


Fig.  267.— Trephining, 


234 


OPERATIVE  SURGERY. 


Pig.  268. — Increasing  the  size  of  the  opening  in  the 
skull  with  the  rongeur. 


the  center  pin  and  fasten  it  back  in  place,  to  prevent  puncturing  the  mem- 
branes of  the  brain.  Continue  the  operation,  raising  the  instrument  from 
the  track  and  freeing  it  from  bone  dust  with  a  brush  provided  for  the  purpose 

(Fig.  265,  t).  Ordinarily 
the  appearances  of  bone 
dust  vary  according  to  the 
advance  of  the  trephine; 
that  of  the  diploe  being 
deeply  stained  with  blood, 
while  that  of  the  tables  of 
the  cranium  is  grayish  in 
color.  The  passage 
through  the  diploe  is 
marked  by  bloody  detritus, 
by  an  easier  and  more 
rapid  advance  of  the  in- 
strument, and  is  attended 
with  a  softer  sound.  While 
going  through  the  internal 
table  less  pressure  should 
be  made  on  the  instrument, 
and  the  circular  movements 
should  be  made  lighter  and  quicker  than  before  to  avoid  a  precipi- 
tate entry  of  the  cranium.  At  frequent  intervals  the  end  of  a  grooved 
director  or  of  a  trephine  probe 
(Fig.  265,  r)  is  introduced  into 
the  track  of  the  instrument  to  as- 
certain if  any  part  of  the  circle 
be  deeper  than  another,  and  if 
the  bone  be  cut  through  at  any 
point.  If  the  button  be  percussed 
with  a  light  metal  instrument 
it  gives  forth  a  low-pitched  sound 
if  complete  division  to  any  ex- 
tent be  present.  When  but  a 
moderate  penetration  of  the  inner 
table  is  present,  the  button  can  be 
moved  and  perhaps  tilted  out  by  an 
elevator,  or  possibly  it  may  come 
away  with  the  trephine,  if  the  latter 
be  carefully  tilted.  If,  after  the 
removal  of  the  button,  additional 
room  be  required,  the  rongeur  (Fig. 
265,  Z  or  m)  is  brought  into  use 
(Fig.  268). 

The  removal  of  the  button  of  bone  enables  the  surgeon  to  insert  the 
point  of  the  elevator  (Fig.  265,  Tc)  beneath  the  depressed  portion  (Fig.  269) 


Fig.  269.— Raising  a  depressed  fragment 
with  an  elevator  passed  through  a  tre- 
phine opening. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


235 


Fig.  370.— Fractures 
of  skull.  Depressed 
fragments.  Com- 
pression of  brain 
from  bone  and 
blood.  Illustrates 
need  of  care  in  ma- 
nipulation of  bony 
fraijments. 


and  to  pry  it  into  place  through  the  agency  of  the  linger  or  the  solid  bone 
border  (a),  acting  as  a  fulcrum.  Great  care  must  be  taken  in  doing  this  or 
the  sudden  giving  way  or  tilting  of  the  fragment  will  injure  the  soft  parts, 
and  also  disconnect  the  fragment  from  nutrient  asso- 
ciations. The  utilization  of  the  rongeur  and  the  mal- 
let and  gouge  (Fig.  2f)5,  /,  g,  s)  to  liberate  the  points 
of  impaction  and  Ijinding  makes  the  elevation  of  the 
fragments  easier  and  safer  (Fig.  271).  Projecting 
points  of  bone  are  cut  away  and  loose  portions  are 
sought  for,  especially  beneath  the  bony  border  of  the 
wound  (Fig.  272).  The  loose  pieces  of  bone  are  kept 
and  fitted  to  each  other  to  ascertain  if  any  portion 
of  bone  be  missing,  especially  if  the  membranes  have 
been  lacerated,  for  then  a  portion  of  bone  may  be 
driven  into  the  brain  and  remain  there  unsuspected. 
Eents  of  the  dura  are  closed  with  fine  catgut  stitches. 
After  proper  scrutiny  of  the  wound  the  technique  of 
closing  and  dressing  it  must-  be  considered.  Much 
difference  of  opinion  is  expressed  regarding  the  best 
plan  of  procedure.  The  cranial  opening  may  he  re- 
paired by  replacement  of  the  fragments,  by  the  in- 
troduction of  a  foreign  body,  or  by  allowing  ISTature  to 
cure  it  after  her  own  manner.  If  the  first  propo- 
sition is  to  be  adopted,  the  fragments,  as  fast  as  removed,  are  wrapped  in 
an  aseptic  towel  saturated  with  hot  sterilized  water  to  preserve  their  vital- 
ity and  purity.  Whether  the  replacement 
of  the  button  intact  or  the  fragmentation 
of  it  and  return  of  the  pieces  is  the  better 
plan  has  caused  some  discussion.  The  ex- 
perience of  the  author  emphasizes  a  pref- 
erence for  the  latter  plan  since  the  bony 
fragments  when  bathed  in  blood  are  more 
viable  than  is  the  button,  which  often  ne- 
croses. The  introduction  into  the  open- 
ing of  a  metallic,  gutta-percha,  or  cellu- 
loid plate  is  a  refinement  in  surgery  which 
often  is  successful  under  strict  asepsis. 
The  conditions  that  make  success  attain- 
able in  this  instance  will  quite  likely 
achieve  a  similar  result  in  the  use  of  bone 
fragments,  and  provide  for  the  patient  a 
vitalized  rather  than  an  inanimate  repair. 
The  too  frequent  occurrence  of  necrosis  of 
the  fragments  and  the  little  practical  util- 
ity gained  by  the  success  of  the  measure 
in  the  majority  of  cases,  has  led  to  its  discontinuance,  except  for  some 
special  reason.     The  torn  borders  of  the  dura  and  the  borders  of  the 


Fig.  371. — The  chiselling  of  a  fissure 
to  liberate  a  point  of  impaction. 


236  OPERATIVE  SURaERY. 

reflected  periosteum  are  united  with  fine  catgut,  the  flaps  are  placed  in 
proper  position  and  united,  horsehair  or  silkworm-gut  drainage  is  provided, 
antiseptic  dressings  are  loosely  applied,  the  head  is  elevated,  and  the  patient 
kept  quiet  by  anodynes  if  need  be,  followed  by  a  brisk  cathartic. 

The  Important  Considerations.-^CTsniia,  vary  in  thickness,  the  average 
in  the  adult  being  about  a  fifth  of  an  inch.  In  youth  and  old  age  they  are 
much  thinner.  The  irregularities  of  the  inner  table  for  the  reception  of 
the  convolutions  of  the  brain  cause  inequalities  in  the  thickness  of  circum- 
scribed portions  of  the  bone  at  numerous  situations.  Some  cranial  bones  are 
thinner  than  others — for  example,  both  in  early  life  and  in  the  aged  the 
diploe  is  absent  from  the  squamous  part  of  the  temporal,  the  contiguous 

portion   of  the  parietal   and 

the    fossae    of    the    occipital 

^*    ^^  bone.     If  these  facts  be  not 

recognized    during    operation 

the  danger  of  injury  to  the 

ll^^^^^^^\     ^^\  cranial  contents  is  manifest. 

("^^^]^^\,     \       ^^^^^^^^M^mF'      Holden's    maxim    for    using 

W         ^\T       \     -■^■F*^     lYie    trephine—"  Think    that 

you  are  operating  on  the  thin- 
-Vw-w  \^""  //  -  nest  skull  ever  seen,  and  thin- 

ner in  one  half  of  the  circle 
than  in  the  other  " — is  a  good 
one.  The  trephine  should  be 
applied  vertically  to  the  plane 

-c     „„o     rru   ^•f^■         4-    *  1  •  *  V,  of  the  part  of  the  skull  at- 

iiG.  272. — 1  he  lifting  out  oi  loose  pieces  of  bone;  -^ 

of  the  internal  table  in  this  instance.  tacked  and  kept  m  this  rela- 

tion to  maintain  an  equality 
in  the  depth  of  the  circular  cut,  thus  avoiding  as  far  as  possible  injury  of 
the  membranes  from  a  premature  division  of  one  side  of  the  button. 

Free  hgemorrhage  from  the  divided  bone  is  usually  arrested  by  elevating 
the  fragment.  If  not,  temporary  tamponing  with  sponge  or  gauze  will  quite 
easily  overcome  it.  However,  if  this  be  not  the  case,  plugging,  ligature, 
crushing,  actual  cautery  (page  352),  and  Horsley's  wax  (page  568)  are  yet 
available  for  use.  If  the  bone  be  comminuted  and  the  fragments  movable, 
they  may  be  elevated  without  the  use  of  the  trephine  (Fig.  372).  In  any  event 
the  trephine  should  be  so  placed  (Fig.  267,  &)  as  not  to  disturb  movable  frag- 
ments (c),  for  fear  of  causing  them  to  cut  or  puncture  the  tissues  lying 
beneath.  In  such  cases  the  fragments  should  be  removed  with  sequestrum 
forceps  (Fig.  265,  n,  p)  and  the  trephine  placed  on  solid  bone.  In  a  case 
with  firmly  depressed  fragments  (Fig.  267,  d),  the  application  of  the 
trephine  should  not  be  delayed  by  attempts  with  less  effective  means. 

In  punctured  fracture  a  large  trephine  is  usually  employed  and  so  placed 
over  the  fracture,  if  possible,  as  to  provide  by  a  single  button  ample  room 
for  the  removal  of  the  fragments  of  the  internal  table. 

The  lodgment  in  fissures  and  in  bony  asperities  of  hairs,  threads,  etc., 
should  be  noted^  and  their  removal  secured  to  prevent  infection. 


OPERATIONS  ON   THE  NERVOUS  SYSTEM. 


237 


Trephining  over  the  course  of  important  vessels  should  be  avoided,  ex- 
cept for  special  reasons.  The  middle  meningeal  artery  and  its  branches, 
and  the  cerebral  sinuses  are  of  special  significance  in  this  regard. 

The  Middle  Meningeal  Artery. — After  entering  the  cranium  the  middle 
meningeal  divides  into  two  branches,  anterior  and  posterior.  The  ante- 
rior branch  runs  in  a 
canal  or  groove  on  the 
inner  surface  of  the  an- 
tero-inferior  angle  of  the 
parietal  bone  (Figs.  273 
and  275),  upward  and  a 
little  backward  to  the 
sagittal  suture  b'ing 
about  three  quarters  of 
an  inch  behind  the  coro- 
nal suture.  At  this  angle 
of  the  bone  it  is  about 
one  inch  behind  the  ex- 
ternal angular  process  of 
the  frontal  bone,  and  one 
inch  and  a  half  to  one 
and  three  quarter  inches 
above  the  zj^goma  (Fig- 
292,  F).  The  posterior 
branch  passes  upward  and 
backward  along  the  inner  surface  of  the  squamous  portion  of  the  temporal 
bone,  lying  in  a  shallow  groove  (Fig.  275),  at  an  angle  of  about  9°  with  the 
upper  border  of  the  zygoma  (Figs.  273,  6,  and  292,  G).  If  the  meningeal 
branch  be  severed  with  the  trephine,  the  haemorrhage  may  be  arrested  by 
ligature,  by  tamponing  by  instrumental  pressure  of  the  bleeding  point 
against  the  inner  table,  trephining  and  tying  the  vessel  at  the  proximal 
side  of  the  injury,  and  by  ligature  of  the  external  carotid.     The  simpler 

methods  usually  are  sufficient 
for  the  purpose  in  all  instances 
except  when  the  bleeding  com- 
plicates a  fissured  fracture  of  the 
skull.  The  presence  of  the  an- 
terior branch  of  the  meningeal 
artery  in  a  canal  (Fig.  27-i) 
exposes  the  vessel  to  much 
greater  danger  of  injury  from 
fracture  or  trephining  at  that 
situation  than  when  running  in 
a    groove    (Fig.    275),    for    ob- 


/  h 

Fig.  273. — Course  of  middle  meningeal  artery. 
a,  b.  Reid's  base  line,     c,  d.  Kronlein's  line,     e,  /.  Ver- 
tical line,  inch  and  a  half  behind  external  angular 
process,    g,  h.  Vertical  line  at  posterior  border  of 
mastoid  process  (page  240,  Pig.  276). 


Pig.  274. — Anterior  branch  of  middle  menin- 
geal artery  occupying  a  canal  at  anterior- 
inferior  angle  of  parietal  bone. 

vious  reasons. 
The  location  of  the  sinuses  are  indicated  sufficiently,  to  avoid  injury 

to  them,  under  the  heading  of 


Dangers  "  on   page   244  and  "  Precau- 


238 


OPERATIVE  SURGERY. 


tions  "  on  page  239,  and  by  Fig.  292,  A,  B.  If  a  sinus  be  opened  the  wound 
is  tied  or  sewed  with  catgut  or  closed  by  compression  with  aseptic  gauze. 

The  Results. — The  nature  of  the  injury,  delay  in  the  performance  of 
the  operation,  and  the  inability  to  execute  the  proper  technique  are  the 
important  factors  that  modify  the  prognosis.  A  fatality  of  from  four  to 
fifteen  per  cent  is  a  fair  estimate  of  the  results  in  civil  practice.  The  death 
rate  from  trephining  alone  is  scarcely  two  per  cent. 

Craniotomy  for  Meningeal  Haemorrhage. — Meningeal  haemorrhage  may 
be  either  epidural  (Fig.  277)  or  subdural  (Fig.  279).  The  former  is  easier 
treatment  and  offers  by  far  the  better  prognosis.    Either  variety  is  commonly 


Fig.  275. — Anterior  branch  of  middle  meningeal  artery  occupying  a  groove  on  anterior- 
inferior  angle  of  parietal  bone. 

associated  with  severe  injuries  of  the  head,  such  as  fracture  of  the  skull, 
laceration  of  the  brain,  etc.  In  depressed  fractures  the  blood  often  escapes 
externally,  or  is  easily  removed  coincident  with  elevation  of  the  bone.  Fis- 
sured fractures  of  the  cranium  are  complicated  frequently  with  extradural 
hsemorrhage,  especially  when  the  fissure  passes  through  the  route  of  the 
branches  of  the  middle  meningeal  artery.  This  variety  of  hsemorrhage, 
although  circumscribed,  is  frequently  extensive.  After  the  localization  of 
the  seat  of  the  blood  clot,  the  preparation  of  the  patient  is  the  same  as  in 
trephining  for  other  purposes  (page  231).  The  formation  of  the  flap,  the 
control  of  the  hemorrhage,  and  the  general  technique  are  similar.  The 
operation  should  be  done  promptly — and  with  chloroform  when  practicable 
— if  angesthesia  is  required. 

Tlie  Oiieraiion. — Make  a  flap  of  large  size  at  the  seat  of  injury,  provided 
the  injury  corresponds  with  the  seat  of  the  haemorrhage,  as  indicated  by  the 
symptoms.  After  exposure  of  the  cranium  seek  for  a  fissure  of  the  skull. 
Apply  a  full-sized  trephine  to  the  cranium — in  the  line  of  the  fissure  if  prac- 
ticable— and  expose  the  blood  clot  beneath.  Remove  the  blood  clot  carefully 
with  thefinger'or  with  a  scoop — a  teaspoon  will  do — aided  by  flushing  with  hot 
sterilized  water.  If  all  hagmorrhage  has  ceased,  drain  the  cranial  wound  with 
horsehair  or  silkworm  gut,  return  the  soft  parts  to  the  normal  places,  unite 
and  dress  the  wound  in  the  usual  manner.  If  hgemorrhage  be  progress- 
ing at  the  time  of  operation  the  occurrence  is  indicated  by  the  following 
facts : 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


239 


Fig.  276. — Vogt's  method  of  locating 
middle  meningeal  artery. 


1.  The  presence  of  extensive  extravasation  of  the  soft  parts  with  fluid 
blood. 

2.  The  free  escape  of  blood  from  a  fissure  fracture. 

3.  The  pulsation  of  the  epidural  clot. 

4.  The  appearance  of  fluid  blood  in  the  epidural  cavity  after  removal 
of  the  blood  clot. 

5.  The  discovery  of  the  bleeding  point  itself  (Figs.  276  and  277). 
The  prompt  arrest  of  the  bleeding  is  of  obvious  importance.     If  the 

bleeding  point  can  be  seen  when  it  lies 
in  the  bone  tissue  the  flow  may  be 
stopped  by  plugging  the  point  with 
catgut;  by  tying  or  by  pressure  of  the 
vessel  against  the  internal  table  by 
means  of  properly  curved  long-bladed 
forceps,  one  blade  being  placed  with- 
out and  the  other  within  the  cranial 
cavity.  If  the  bleeding  point  can 
not  be  seen  the  application  of  cold  to 
the  head,  temporary  sponge  or  gauze 
pressure,  or  pressure  on  the  common 
carotid  should  be  tried.  However,  in 
either  case,  if  the  bleeding  persist,  it 
can  be  arrested  by  ligature  of  the  ex- 
ternal carotid,  or  better  by  trephining,  and  ligaturing  the  vessel  at  the 
proximal  side  of  the  bleeding  point,  after  which  the  wound  is  drained  and 
treated  antiseptically  (Fig.  278). 

If  the  compression  symptoms  be  of  indefinite  charac- 
ter and  no  fracture  be  found,  Kronlein  advises  as  fol- 
lows: "Draw  a  line  around  the  skull  from  the  upper 
margin  of  the  orbit  (Fig.  273,  c,  d)  parallel  throughout 
with  Eeid's  base  line  (Fig.  273,  a,  h).  At  a  point  from 
one  inch  and  a  quarter  to  one  inch  and  a  half — accord- 
ing to  the  size  of  the  head — from  the  external  angular 
process,  apply  the  trephine  (A)  and  explore  for  hajuior- 
rhage  (Fig.  276).  If  the  conditions  indicate  involvement 
of  the  posterior  branch,  the  latter  may  be  exposed  liv  a 
trephine  opening  (B)  on  the  same  line  where  it  is  inter- 
sected by  a  vertical  line  drawn  from  the  posterior  border 
of  the  mastoid  process."  Thumb  in  front  and  two 
fingers  below  (Fig.  276). 

The  Precautions. — The  absence  of  a  fissure  of  the 
cranium  at  the  seat  of  external  injury  is  no  proof  that  a 
fissure  is  not  present.  ISTot  infrequently  in  these  cases  the 
fissure  begins  at  an  extreme  limit  or  even  outside  of 
the  external  wound,  therefore  the  injured  and  adjoin- 
ing areas  should  l)e  carefully  searched,  otherwise  the  fracture  will 
escape- notice.  A  minute  fissure  may  be  confounded  with  a  suture,  or 
with  an  incision  through  the  pericranium.     The  irregularity  and  direc- 


PiG.  277.— Fissure  of 
skull  with  ei)idu- 
ral  haemorrhage. 


240 


OPERATIVE  SURGERY. 


tion  of  the  former  and  the  shallow  and  fickle  borders  of  the  latter  will 
readily  discriminate  between  them.     The  tamponing  of  the  clot  cavity  to 

arrest   haemorrhage   should 


not  be  favorably  regarded, 
since  to  be  effectual  the 
tampon  must  exercise  as 
great  pressure  at  least  as 
did  the  blood  clot  itself. 

Ligature  of  the  common 
carotid  should  not  be  en- 
tertained in  this  connec- 
tion because  of  the  high 
rate  of  mortality  (forty  per 
cent)  following  this  pro- 
cedure; the  external  carot- 
id should  be  tied  instead, 
as  the  rate  following  its 
ligature  is  less  than  four 
per  cent.  If  no  epidural 
clot  (Fig.  278)  be  present  a 
subdural  one  should  be 
sought  for  (Fig.  279). 

The  Results. — The  re- 
sults depend  very  much  in- 
deed on  the  character  and 


Fig.  278.— Epidural  clot.  Rupture  of  middle  menin- 
geal artery.  Trephine  followed  by  rongeur  to  local 
seat  of  bleeding.     Arrest  with  suture. 


extent  of  cerebral  complications. 
However,  the  statistics  of  Weis- 
man  amply  demonstrate  the  wis- 
dom of  the  measure.  According 
to  his  report  89.1  per  cent  died 
with  the  expectant  treatment,  and 
but  32.7  per  cent  died  after  oper- 
ative treatment. 

Subdural  Haemorrhage. — Sub- 
dural haemorrhage  arises  from  the 
effects  of  traumatism,  from  pachy- 
meningitis, and  from  unknown 
causes.  The  clot  may  be  a  recent 
or  an  old  one,  and  may  be  of  arte- 
rial, venous,  or  capillary  origin.  If 
arterial  the  middle  meningeal  or 
basilar  vessels  are  usually  at  fault. 
If  venous  it  is  frequently  associated 
with   abnormalities   of   the   veins 


Fig.  279.— Subdural  clot,  exposed  by  division  of 
dura  after  removal  of  part  of  skull. 


OPERATIONS  ON  THE   NERVOUS  SYSTEM.  241 

connected  with  the  superior  longitudinal  sinus.  If  capillary  it  is  often  the 
result  of  local  traumatism.  It  is  of  special  importance  to  note  the  possibility 
of  the  presence  of  free  blood  beneath  the  dura  subjacent  to  a  fracture  of  the 
skull.  Subdural  hsemorrhages  are  rarely  indeed  circumscribed,  and  often 
cover  the  entire  surface  of  a  cerebral  hemisphere.  If  subdural  hemorrhage 
complicate  a  fracture  of  the  skull  the  elevation  of  the  bone  or  the  removal 
of  the  epidural  clot  gives  but  little  if  any  relief  to  the  patient.  In  such  cases 
the  exposed  dura  bulges  into  the  cranial  opening  somewhat,  and  the  brain 
pulsations  can  not  be  seen  or  felt,  or  are  present  only  in  a  limited  degree. 

The  Operation. — Increase  the  size  of  the  opening  in  the  cranium  so  as 
to  correspond  to  the  recognized  area  of  compression ;  at  the  most  dependent 
point  make  an  oval  incision  in  the  dura  with  a  curved  bistoury  a  quar- 
ter of  an  inch  from  the  bone  margin ;  arrest  all  bleeding ;  carefully  draw 
aside  the  dural  flap  with  a  tenaculum ;  incise  the  arachnoid  membrane  cau- 
tiously with  bent  scissors,  and  draw  it  aside  so  as  to  expose  the  blood  clot, 
which  is  then,  with  bits  of  sponge,  wiped  carefully  away.  If  firmer  agents 
than  these  be  employed  to  remove  or  dislodge  the  clots,  great  care  is  needed 
to  prevent  injury  of  the  brain  and  increase  of  haemorrhage.  Haemorrhage 
of  the  dura  is  promptly  and  finally  controlled  by  a  catgut  ligature  passed 
by  the  aid  of  a  needle  through  the  membrane  near  to  the  border  around 
the  vessel  and  tied.  Haemorrhage  from  the  pia  is  commonly  arrested  by 
patiently  applied  sponge  or  gauze  pressure.  Serre-fines  (Fig.  265,  o)  and 
fine  catgut  ligatures  are  employed  if  pressure  be  inefficient.  Haemorrhage 
from  the  brain  is  usually  controlled  by  sponge  or  gauze  pressure ;  adrenalin 
ought  and  caut-ery  can  be  employed.  Park  advises  a  solution  of  1  to  40 
of  antipyrin,  and  Keen  a  solution  of  cocaine  1  to  100  for  this  purpose. 
After  the  removal  of  the  blood  clot  and  the  arrest  of  haemorrhage,  the  bor- 
ders of  the  divided  dura  are  united  by  a  continuous  suture  of  fine  catgut, 
except  for  a  short  distance  at  the  most  dependent  portion;  at  this  point 
horsehair  drainage  is  provided  and  the  remaining  portion  of  the  wound 
lightly  jDacked  with  aseptic  gauze,  which  is  in  turn  covered  with  an  al)un- 
dance  of  carbolic  or  bichloric  gauze,  bound  tightly  in  position.  The  head  and 
shoulders  are  elevated,  and  the  patient  is  quieted  by  anodynes  if  necessary. 
Subdural  licemorrhage  unassociated  with  fracture,  when  the  seat  of  the 
extravasation  is  established,  and  when  the  condition  of  the  case  will  justify, 
should  be  treated  in  a  similar  manner.  The  author  has  in  three  instances 
removed  what  was  possible  of  an  extensive  subdural  extravasation  of  blood. 
In  one  instance  only  was  there  evidence  of  fracture.  In  all  cases  temporary 
amelioration  of  the  symptoms  followed  the  escape  of  an  abundance  of  sero- 
sanguinolent  fluid.  In  each  instance  the  patient  succumbed,  on  account  of 
extensive  fracture  of  the  base  of  the  skull  and  the  extravasation  of  blood. 

TJie  Results. — The  not  infrequent  favorable  reports  of  operations  for 
relief  in  subdural  haemorrhage  of  both  recent  and  remote  occurrence  are 
sufficiently  assuring  to  justify  continued  efforts  in  this  direction  in  proper 
cases  and  with  strict  aseptic  technique. 

Craniotomy  (Linear)  for  Microcephalus. — The  term  microcephalus  is  ap- 
plied to  an  abnormality  of  the  brain  characterized  by  diminished  size,  and 


24:2  OPERATIVE  SURGERY. 

also  enfeebled  and  distorted  functions  of  the  organ,  associated  with  congen- 
ital and  premature  closure  of  the  fontanelles  and  sutures  of  the  cranium. 
This  unnatural  closure  of  the  osseous  envelope  of  the  brain  was  regarded  at 
first  as  the  chief  cause  of  the  singular  mental  exhibitions  of  these  patients, 
and  they  were  thought  to  depend  on  the  arrest  of  cerebral  development  coin- 
cident with  the  pressure  imposed  on  the  organ  by  the  limited  capacity  of  the 
cranial  cavity.  In  the  presence  of  this  belief,  it  is  not  strange  that  operative 
measures  contemplating  the  loosening  of  the  brain  from  the  unnatural  beset- 
ment  were  promptly  planned  and  executed.  It  is  to  be  regretted,  however, 
that  the  operative  procedure  itself  often  proves  unexpectedly  and  unac- 
countably fatal,  and  that  the  curative  outcome  is  very  disheartening. 

Having  carefully  determined  the  case  to  be  a  proper  one  and  in  suitable 
condition  for  operation,  prepare  the  patient  in  the  manner  proper  in  crani- 
otomy for  fracture  (page  231).  Before  making  the  scalp  flap,  suitable  meas- 
ures should  be  taken  to  avoid  loss  of  blood.  Circumferential  elastic  pres- 
sure made  by  strong  rubber  bands  resting  on  and  holding  in  position  small 
firm  compresses  placed  over  the  main  arteries  supplying  the  scalp,  or  the 
control  of  these  vessels  by  acupressure  and  digital  pressure  are  advised. 
However,  if  the  bleeding  points  be  j)romptly  caught  the  loss  of  blood  from 
the  scalp  will  play  no  important  part  in  the  result. 

The  Operation  of  Linear  Craniotomy. — The  site  of  the  operation  is  ex- 
posed by  a  free  incision  of  the  scalp  down  to  the  pericranium,  and  from  the 
hair  line  in  front  backward  to  the  occipital  protuberance,  an  inch  from  and 
parallel  with  the  sagittal  suture.  This  incision  is  supplemented  by  a  short 
one  at  either  end  passing  downward  and  outward.  The  scalp  flap  is  drawn 
aside  and  held  with  loops  of  silk  passed  through  the  border  at  tAVO  or  three 
situations.  A  button  of  bone  about  an  inch  in  width  is  removed  from  the 
center  of  the  operation  field  by  a  trephine  applied  not  less  than  one  inch 
and  a  half  from  the  sagittal  suture.  Beginning  at  the  opening  first  made, 
separate  the  dura  from  the  bone  with  a  narrow,  flexible  spatula  (Fig.  290,  i), 
allowing  it  to  remain  in  position  to  protect  the  dura  from  injury  (see  Menin- 
gitis, page  244),  the  bone  is  cut  through  parallel  with  the  sagittal  suture 
nearly  to  the  limits  of  the  incision  of  the  soft  parts  by  means  of  Hof mann's 
bone-cutting  forceps,  rongeur  (Fig.  265,  I,  m),  chisel  and  mallet,  or  by  saw- 
ing. The  use  of  the  chisel  and  mallet  requires  the  employment  of  much 
force,  causing  objectionable  vibration  of  the  structures  of  the  head;  they  are 
therefore  used  now  less  frequently  than  before,  the  saw  and  bone-cutting 
forceps  being  employed  instead.  Sawing  is  the  quicker  and,  |)erhaps,  the 
safer  means,  and  should  be  employed  when  practicable.  In  order  to  secure 
a  prompter  and  greater  increase  of  capacity  of  the  cranial  cavity,  lateral 
divisions  of  the  skull  are  sometimes  made.  Various  other  forms  of  bone 
incision  are  also  recommended  (Chipault)  (Fig.  280).  If  the  lateral  bone 
sections  are  to  be  made  by  sawing,  the  removal  of  a  small  button  of  bone  at 
the  point  of  beginning  of  each  will  enable  the  operator  to  apply  the  saw 
more  satisfactorily  and  effectively  at  these  points  for  obvious  reasons.  The 
immediate  and  forcible  elevation  of  a  parietal  bone  when  thus  divided  does 
not  commend  itself  as  wise  or  essential  in  a  known  degree  to  the  purpose  of 


OPERATIONS   ON   THE   NERVOUS  SYSTEM. 


243 


the  operation.  But  that  the  hone  may  l)e  sprung  upward  at  tliis  time  sufTi- 
ciently  to  test  its  yielding  nature  with  no  liarm,  and  perliaps  with  henefit,  is  a 
reasonahle  conclusion.  Whether  or  not  a  narrow  strip  of  bone  should  be  re- 
moved along  the  antero-posterior  line  of  section  must  be  decided  at  the  time 
of  the  operation,  for  certainly  it  should  not  ])e  attempted  if  the  safety  of 
the  patient  will  be  compromised  by  the  act.    The  removal  en  masse  of  large 


Fig.  2y0. — Sections  of  cranial  bones. 


areas  (Fig.  280,  a)  of  bone  corresponding  to  a  depressed  surface  is  practiced 
with  comparatively  no  unfavorable  results,  and  seemingly  with  prompter  bene- 
fit than  from  more  limited  removal.  Powell's  electric  saw,  driven  by  an  easily 
portable  motor,  is  a  capital  contrivance  for  the  purpose  (Fig.  281).  When 
a  change  in  the  direction  of  the  sawing  is  desirable,  an  additional  trephine 
opening  at  the  proper  site  meets  the  requirement.  The  dental  engine  can  be 
used  to  drive  the  saw,  but  is  less  effective  in  all  respects  than  is  the  former. 
The  Gigli-Haertel  wire  saiv  (Fig.  265,  i)  is  a  recent  and  valuable  addi- 
tion to  the  armamentarium  of  bone  sawing.  In  the  instance  of  craniotomy 
the  saw  is  carried  through  the  trephine  openings  beneath  the  bone  and  above 
the  spatula  employed  in  the  detachment  of  the  dura  by  means  of  a  long 


,....i-::===-'^=~^         Pig.  281. — Powell's  electric  saw. 


probe  with  string  attachment.  The  handles  (Fig.  205)  are  then  affixed  and 
the  instrument  operated  as  is  the  chain  saw.  Bone  flaps  of  varying  size  and 
shape  can  be  formed  with  this  instrument. 

It  may  happen  in  this  operation  that  the  bone  section  should  extend 
farther  to  the  front  than  has  been  described  above  or  be  limited  to  the  an- 


244  OPERATIVE  SURGERY. 

terior  part  of  the  cranium  or  to  the  motor  area  alone,  depending  on  the 
manifestations  exhibited  by  the  patient ;  and,  too,  exploration  beneath  the 
dura  mater  may  be  regarded  as  admissible  and  even  necessary  in  some  cases. 
After  the  arrest  of  haemorrhage  the  skin  wound  is  closed  with  silkworm  gut 
and  dressed  antiseptically.  The  patient  should  be  kept  quiet  by  the  use  of 
the  bromides,  if  advisable,  until  the  wound  is  healed.  Drainage  need  not 
be  employed  unless  for  some  special  reason. 

The  Dangers. — The  danger  from  heemorrhage  is  considerable,  especially 
in  those  cases  possessed  of  highly  vascularized  diploeic  structure.  In  such 
cases  it  is  sometimes  necessary  to  stop  the  operation  on  account  of  the  great 
loss  of  blood.  The  author  once  encountered  a  case  of  this  kind.  If  the 
bleeding  come  from  definite  points  of  the  cancellous  tissue,  it  can  be  arrested 
by  plugging  the  opening  with  catgut,  or  by  aid  of  the  actual  cautery  or  the 
heated  point  of  a  probe  (see  page  336).  If  the  bleeding  from  the  bone  be 
general  the  gauze  tampon  firmly  applied  along  the  line  of  section  will  arrest 
it.  Injury  of  the  longitudinal  sinus  will  cause  free  hemorrhage.  Fortu- 
nately, however,  the  demands  of  the  operation  do  not  require  a  close  ap- 
proach to  this  important  vessel.  It  is  not  amiss  to  recall  the  fact  that  the 
sinus  is  quite  narrow  in  front  and  increases  in  width  as  it  passes  backward, 
and  also  that  it  encroaches  more  on  the  left  than  the  right  parietal  bone 
at  the  posterior  part. 

Shock  is  an  important  element  of  danger  in  these  cases.  It  is  caused 
sometimes  by  the  loss  of  blood  and  also  by  the  violence  inflicted  in  the  oper- 
ation. In  not  a  few  instances  the  depth  of  the  shock  can  not  be  satisfac- 
torily accounted  for.  While  cases  differ  much  in  this  regard,  still  the  rule 
is,  the  longer  the  time  employed  in  the  operation  and  the  greater  the  meas- 
ure of  violence,  the  more  profound  is  the  degree  and  the  danger  from  shock. 
For  this  reason,  operation  on  both  sides  of  the  head  at  the  same  sitting  is 
not  favorably  regarded ;  and,  moreover,  if  a  considerable  interval  between 
the  operations  be  allowed,  one  is  enabled  to  judge  of  the  advisability  of  a 
second  operation  by  the  results  arising  from  the  first. 

Me7iingitis. — Meningitis  is  an  infrequent  sequel  of  the  operation,  and  is 
often  provoked  by  the  rough  handling  or  carelessness  of  the  operator.  The 
danger  of  injuring  the  dura,  except  with  the  saw,  is  trivial,  and  can  be  easily 
obviated  by  passing  between  it  and  the  cranium  a  thin,  flexible  strip  of  metal 
which  is  held  firmly  in  position  during  the  act  of  sawing  (Fig.  290,  i).  If 
the  strip  of  metal  be  grooved  along  the  uppermost  surface  sufficiently  to 
leave  an  appreciable  space  between  it  and  the  bone,  the  bone  can  then  be 
divided  entirely  with  a  minimum  danger  of  injury  of  the  soft  parts. 

Thrombosis  and  Pymmia. — If  the  wound  becomes  infected  and  the  can- 
cellous tissue  of  the  cranial  bones  is  involved,  then  much  danger  from 
pyaemia  arises.  If  proper  aseptic  precautions  are  taken  at  the  outset  and 
maintained  during  the  operative  and  subsequent  treatment,  there  is  no 
likelihood  of  infection. 

The  Results. — While  the  ultimate  results  do  not  as  yet  establish  the  oper- 
ation on  a  firm  basis,  still  it  offers  to  many  cases  the  only  known  hope  of  even 
a  temporary  improvement.    The  present  inability  to  determine  the  patholog- 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


245 


ical  condition  of  the  brain  before  exploration  has  much  to  do  with  the  un- 
favorable results  that  follow  it.  Still,  the  hopelessness  of  the  condition, 
and  the  undoubted  benefits  that  have  followed  operation  in  isolated  cases, 
should  encourage  a  studied  perseverance  in  this  direction  until  a  better 
means  of  relief  is  ascertained.  Promptly  after  the  operation  the  temperature 
reaches  a  high  figure  in  some  cases,  and  with  fluctuations  remains  there  for 
days,  unless  death  ensues.  The  author  has  in  mind  a  case  of  his  own  in 
which  death,  with  high  temperature,  happened  within  a  week,  with  no 
physical  or  bacteriological  evidence  to  account  for  it.  The  death  rate  from 
the  operation  is  variously  stated  as  being  from  two  to  seventeen  per  cent. 
The  best  results  occur  in  those  over  ten  years  of  age. 

Craniotomy  for  Brain  Tumor. — The  brain,  like  other  tissues  of  the  body, 
suffers  from  the  presence  of  nearly  every  variety  of  morbid  growth.  The  as- 
certainment of  the  functions  of  certain  portions  of  the  encephalon  enables 
the  diagnostician  to  locate  the  situation  of  tumors  in  many  instances  by  a 
careful  analysis  of  the  disordered  manifestations  provoked  by  the  presence 
of  these  growths  in  the  brain.  In  order  to  indicate  on  the  cranium  the 
proper  seat  of  operation  for  the  removal  of  brain  tumors,  it  is  necessary  to 
recognize  the  situation  of  certain  established  points  of  reckoning,  and,  from 
a  knowledge  of  these,  indicate  the  definite  part  of  the  cranium  that  covers 
the  disordered  brain  center. 

Craniocerebral  Topography. — The  expression  craniocerebral  topography 
applies  to  the  localization  of  important  brain  fissures  and  centers  by  aid  of 


nssuRr  CF  RCLA^oa 


POSITION  OF 
PAR  IE  TAL 
EMINENCE 


POSITION  OF  FRON- 
TAL EMINENCE. 


FISSURE  OF 
SYLVIUS, 


SUP.TEMPDRAL  FISSURE. 


MIDDLE 
TEMPORAL  nSSURE. 


Fig.  282. — Relation  of  cerebral  fissures  to  the  cranial  sutures  in  the  adult. 


the  bony  landmarks  of  the  skull.     The  proDiinences,  ridges,  sutures,  and 
the  specially  designated  points  of  reckoning  need  not  be  considered  in  detail 
now,  since  their  location  and  importance  w411  develop  during  the  cranial 
18 


246 


OPERATIVE  SURGERY. 


survey.  In  order  to  locate  imiDortant  cerebral  parts  it  is  necessary  to  make 
definite  measurements  of  the  cranium.  The  relations  of  the  sutures  to  the 
cerebral  fissures  and  convolutions  are  matters  of  great  consequence  in  these 
measurements  (Fig.  283). 

It  is  wise  to  note  at  the  outset  that  the  relations  between  sutures  and 
eminences  of  the  skull  and  the  fissures  and  convolution  of  the  brain  are  not 
unvarying.  For  instance,  the  squamous  suture  may  be  above,  below,  or 
quite  on  a  line  with  the  Sylvian  fissure.  The  parietal  eminence  may  vary 
half  an  inch  in  the  vertical  and  an  inch  in  the  horizontal  direction  (Ander- 
son and  Makin).  The  relation  between  the  bregma  and  lambda  and  gla- 
bella and  inion  vary  considerably  in  different  cases.  The  Sylvian  fissure  is 
more  oblique  in  children  up  to  the  third  or  fourth  5^ear,  and  lies  farther  above 
the  squamous  suture  (Fig.  383)  (Foulhauze).  At  this  age,  too,  the  upper 
end  of  the  Eolandic  fissure  is  usually  a  little  anterior  to  its  site  in  adults. 


FISSUREQF 
SYLVIUS. 


SUP.TEMPORAL  FISSURE. 


Fig.  283. — Relation  of  cerebral  fissures  to  cranial  sutures  m  the  child. 


The  Central  or  Fissure  of  Rolando. — The  central  or  fissure  of  Eolando 
is  the  most  important  of  the  fissures  connected  with  cerebral  localization. 
It  passes  downward  and  forward  on  the  outer  surface  of  the  cerebrum  be- 
tween the  ascending  frontal  and  parietal  lobes,  about  three  and  a  half 
inches,  forming  an  angle  of  sixty-seven  degrees  with  the  median  line  of  the 
cranium  (Figs.  '388  and  389).  It  is  located  by  either  of  the  following  topo- 
graphical plans  (Figs.  385,  386,  287,  and  388)  or  by  mechanical  means  (Fig. 
384)  devised  for  the  purpose.  Horsley's  -fissure  meter  is  calculated  to  fulfill 
the  requirements  of  each  class  of  cases.  Horsley,  finding  that  the  angle 
between  the  central  and  longitudinal  fissures  varied  somewhat  with  the  shape 
of  the  head,  as  modified  by  the  cephalic  index,  devised  an  instrument  provided 
with  a  rotating  arm  corresponding  to  the  central  fissure,  which  can  be  varied 
to  meet  the  deviations  of  the  various  cranial  indices.  The  degree  of  the  cranial 
index  is  determined  by  dividing  the  transverse  diameter  of  the  head  by  the 
antero-posterior  diameter.  According  to  Horsley,  in  a  head  with  a  cranial 
index  of  0.75  the  central  fissure  runs  at  an  angle  of  69°,  the  angle  increasing 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


247 


Fig.  284. — Horslev's  fissure 
meter. 


or  diminishing  one  degree  for  every  two  degrees  increase  or  decrease  in  the 
cranial  index.  The  instrument  is  so  applied  to  the  head  (Fig.  28-4)  that  the 
movable  arm  at  its  center  of  rotation  will  correspond  to  the  upper  end  of 
the  central  fissure.  The  arm  can  be  rotated  to  conform  to  the  cranial  index 
as  established  by  measurements  already  stated. 
Chiene's  method  of  determining  the  position 
of  the  fissure  is  ingenious,  available,  and  ef- 
fective (Fig.  285).  He  folds  a  square  piece  of 
paper  once,  so  as  to  form  a  triangle  ABC, 
the  corners  B  and  D  coinciding.  The  angle 
B  A  C  is  one  of  45°.  The  dotted  edge  D  A  is 
folded  back  so  that  the  dotted  edge  D  A  is 
applied  to  the  dotted  line  C  A.  Each  of  the 
angles  DAE  and  E  A  C  is  evidently  half  of 
45°— that  is,  22.5°.  Leaving  the  flap  DAE 
folded,  the  paper  is  unfolded  at  the  line  C  A, 
forming  the  figure  A  B  C  E.  The  angle  B 
A  E  being  made  up  of  one  of  45°  and  one  of 
22.5°,  is  evidently  67.50°,  which  is,  for  prac- 
tical purposes,  near  enough  to  the  direction 
of  the  fissure  of  Eolando.    The  side  A  B  (B 

in  front)  is  then  applied  to  the  middle  line  of  the  head,  the  angle  A  heing 
placed  half  an  inch  behind  the  midpoint  between  the  glabella  and  inion, 
when  the  line  A  E  corresponds  to  the  fissure  of  Eolando.  In  all  in- 
stances the  lower  third  of  the  fissure  is  more 
nearly  vertical  than  the  remaining  portion  of 
it.  In  children  under  nine  years  of  age  the 
fissure  lies  farther  forward,  and  is  placed  more 
obliquely  than  as  just  described. 

The  Fissure  of  Sylvius. — The  fissure  of 
Sylvius  is  located  promptly  by  drawing  a  line 
parallel  with  Eeid's  base  line  (Fig.  286, A)  back- 
ward from  the  external  angular  process  of  the 
frontal  bone,  e.a.p.^sin  inch  and  a  quarter,  then 
directly  upward  to  a  point  a  quarter  of  an  inch 
above.  From  this  point  draw  a  line  backward 
and  upward  to  a  point  three  quarters  of  an  inch 
below  the  most  prominent  part  of  the  parietal 
eminence  -|- ;  the  line  between  the  two  points 
lies  over  the  fissure  of  Sylvius  (Eeid) .  The  first  three  quarters  of  an  inch  of 
this  line  lies  over  the  main  fissure,  and  the  remainder  over  the  horizontal  por- 
tion. The  main  fissure  bifurcates,  therefore,  two  inches  behind  and  a  quarter 
of  an  inch  above  the  external  angular  process  of  the  frontal  bone.  The  as- 
cending arm  of  the  fissure  {Sy.  a.  f.)  is  about  three  quarters  of  an  inch  long, 
and  lies  directly  behind  the  coronal  suture.  The  horizontal  arm  is  about  four 
inches  in  length.  The  schemes  of  Anderson  and  Makin  (Fig.  287)  and  Lucas- 
Championniere  (Fig.  288)  are  commended  for  the  localization  of  this  fissure. 


D  E  C 

Fig.  285.— Chiene's  method  of 
locating  the  direction  of  the 
fissure  of  Rolando. 


248 


OPERATIVE   SURGERY. 


The  Parieto-occipital  Fissure. — The  portion  of  this  fissure  on  the  upper 
surface  of  the  cerehrum  runs  outward  for  about  an  inch  at  right  angles  with 
the  longitudinal  fissure  (Figs.  282  and  283).  If  the  line  indicating  the  loca- 
tion of  the  fissure  of  Sylvius  be  extended  directly  to  the  median  line  (Fig. 
286,  A)  of  the  cranium,  the  last  inch  of  the  line  (p.  o.  f.)  lies  above  the  upper 
portion  of  the  parieto-occipital  fissure.  The  external  portion  of  the  fissure 
varies  more  in  location  than  any  of  the  other  important  fissures.  However, 
the  whole  or  some  portion  of  it  is  easily  exposed  through  a  properly  located 
opening  an  inch  in  diameter. 


Fig.  286,  A  and  B.— Reid's  Lines. 

A  base  line  (Fig.  A)  is  formed  extending  from  the  lower  margin  of  the  orbit  to  the  cen- 
ter of  the  external  auditory  meatus,  thence  directly  backward,  U,  Q.  F,  G,  D,  E  are 
two  perpendicular  lines  drawn  from  the  longitudinal  fissure  to  the  base  line,  one  pass- 
ing across  the  depression  in  front  of  the  ear,  the  other  along  the  posterior  border  of 
the  mastoid  process.  F,  H  a  line  drawn  from  the  upper  end  of  the  posterior  perpen- 
dicular line  to  the  point  of  junction  of  the  anterior  perpendicular  one  with  the  line 
indicating  the  course  of  the  fissure  of  Sylvius,  and  corresponding  to  the  central  or 
fissure  of  Rolando ;  e.  a.  p.,  external  angular  process.  +  The  parietal  eminence ;  a 
(Fig.  B),  convex  line  indicating  lower  boundary  of  the  parietal  lobe;  1.  fr.  c,  first  or 
superfrontal  convolution ;  1.  fr.  /.,  first  frontal  or  superfrontal  fissure  separating  the 
first  from  the  second  frontal  convolution  (2.  fr.  c.) ;  2.  fr.  /.,  second  frontal  fissure 
separating  second  (2.  fr.  c.)  from  third  (3.  fr.  c.)  frontal  convolutions ;  /.  Ji.,  central  or 
fissure  of  Rolando  ;  asc.  fr.  con.  ascending  frontal  convolution  ;  asc.  par.  eon.,  ascend- 
ing parietal  convolution ;  Sy.  f.  fissure  of  Sylvius ;  Sy.  h.  /.,  horizontal,  and  Sy.  a.  /., 
ascending  limb  of  Sylvian  fissure  ;  p.  o.  /.,  parieto-occipital  fissure ;  i.  par.  f,  inter- 
parietal fissure ;  ang.  g.,  angular  gyrus ;  s.  to.  c,  supermarginal  convolution  ;  1.  t.  s.  c., 
supertemporal  convolution;  1.  t.s.f,  supertemporal  fissure,  separating  first  supertem- 
poral  convolution  (1.  t.  s.  c.)  from  the  second  temporo-sphenoidal  convolution  (2.  t.  s.  c.) ; 
third  temporo-sphenoidal  convolution  (3.  t.  s.  c.)  separated  from  the  second  (2.  t.  s.  c.) 
by  the  second  temporo-sphenoidal  fissure  (2.  t.  s.  f.) ;  1.  2.  and  3.  o.  c.,  first,  second, 
and  third  occipital  convolutions;  p.p.l.,  superior  parietal  convolution  (post-parietal 
lobule). 


The  Longitudinal  Fissure. — The  longitudinal  fissure  is  situated  beneath 
a  line  drawn  from  the  glabella  to  the  inion  (Fig.  287,  G,  I). 

TJie  Transverse  Fissure. — The  position  of  this  fissure  is  indicated  by  a 
line  drawn  directly  from  the  outer  auditory  meatus  to  the  inion.     The  line 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


249 


corresponds  with  the  sii])crior  curved  line  of  the  occipital  hone,  and  marks, 
therefore,  the  junction  of  the  head  and  neck  posteriori}^ — a  fact  of  great 
importance  in  connection  with  operations  directed  to  the  cerebellar  fossae. 

The  Intra- parietal  Fissure. — Preparatory  to  localizing  this  fissure  (Fig. 
289),  define  the  positions 
of  the  central.  Sylvian, 
and  parieto-occipital  fis- 
sures and  the  parietal 
eminence  (Fig.  286,  B). 
This  fissure  corresponds 
to  a  curved  dotted  line 
drawn  from  a  point  four 
fifths  of  an  inch  behind 
the  bend  of  the  fissure 
of  Eolando(Fig.  286,  B) 
upward  and  backward 
midway  between  this  fis- 
sure and  the  parietal  emi- 
nence, thence  downward 
and  backward  in  a  curved 
manner  midway  between 
the  parietal  eminence  and 
the  longitudinal  fissure 
to  and  a  little  below  the 
outer  end  of  the  parieto- 
occipital fissure. 

The  precentralor  Ver- 
tical Frontal  Fissure. — 
This  fissure  lies  nearly 
parallel  with  and  just  be- 
hind the  coronal  suture. 
Its  lower  end  is  two  fifths 
of  an  inch  (one  centi- 
metre) above  the  Sylvian 
fissure  and  a  twelfth  of  an 
inch  behind  the  coronal 


Fig.  287. — Anderson  and  Makin's  Lines. 

G,  glabella ;  I,  inion  ;  G  I,  sagittal  line  ;  M,  mid-sagittal 
line  point ;  A,  external  angular  point  (most  external 
point  of  the  external  angular  process,  and  on  a  level 
with  the  superior  border  of  the  orbit) ;  S,  squamosal 
point  (at  intersection  of  frontal  line,  E  M,  and  mid- 
dle and  upper  thirds  of  the  oblique  line,  A  P);  P, 
parietal  point  (termination  of  oblique  line  and  equi- 
distant with  b  from  squamosal  point,  S);  U,  preau- 
ricular point  (just  in  front  of  the  ear  and  at  the  level 
of  the  upper  border  of  the  meatus) ;  a,  beginning  of 
the  fissure  of  Sylvius  (five  twelfths  of  the  distance 
from  A  to  S) ;  h,  hi  furcation  of  the  fissure  of  Sylvius 
(seven  twelfths  of  the  distance  J.  to  jS";  an  inch  and 
a  half  to  two  inches  from  A) :  d,  termination  of  the 
fissure  of  Sylvius  (half  an  inch  above  P,  in  direction 
parallel  with  frontal  line,  E  31) ;  Ce,  central  fissure 
(the  upper  end,  C,  three  eighths  of  an  inch  behind 
mid-sagittal  point,  M);  e,  loiver  end  of  central  fissure 
(three  eighths  of  an  inch  in  front  of  squamosal  point, 
S) ;  0,  parieto-occipital  fissure  (seven  twelfths  of  the 
distance  from  31  io  I);  A  P,  oblique  or  squamosal 
line ;  E  31,  frontal  line. 


suture.  It  is  placed  about 

four  fifths  of  an  inch  in  front  of  the  central  fissure  (Figs.  282  and  289). 

The  suhfrontal  fissure  extends  from  the  precentral  fissure  to  a  little 
above  the  superior  Stephanion,  thence  forward,  corresponding  nearly  to  the 
frontal  part  of  the  temporal  ridge  (Figs.  282  and  289). 

The  superfrontal  fissure  commences  at  a  point  four  fifths  of  an  inch  in 
front  of  the  central  fissure  and  about  an  inch  and  a  half  from  the  longi- 
tudinal fissure  (Figs.  282  and  289),  and  passes  forward  in  a  varying  line 
practically  parallel  with  the  latter,  and  ends  opposite  the  supra-orbital 
notch. 

The  posterior  cornu  corresponds  to  a  point  one  and  three  quarter  inches 


250 


OPERATIVE  SURGERY. 


below  the  parietal  eminence  (-|-)  and  two  inches  and  a  quarter  from  the 
surface  (Agnew). 

The  angular  gyrus  corresponds  to  the  point  of  junction  of  the  posterior 
perpendicular  line  (Fig.  286^  B)  with  a  direct  extension  to  it  of  the  Sylvian 
line  (Agnew). 

Poirier^s  Nasolambdoidal  Line. — Beginning  at  the  naso-frontal  groove, 
draw  a  line  outward  around  the  base  of  the  skull,  passing  a  quarter  of  an 
inch  above  the  external  auditory  meatus  to  a  point  two  fifths  of  an  inch 
above  the  lambda,  or  to  a  point  two  and  four  fifths  inches  above  the  inion  if 
the  lambda  can  not  be  felt.  This  line  passes  over  Broca's  convolution,  one 
and  a  half  to  two  and  a  half  inches  of  the  posterior  limb  of  the  Sylvian 
fissure,  the  inferior  border  of  the  supra-marginal  convolution,  base  of  the 
angular  gyrus,  and  terminates  at  the  parieto-occipital  fissure. 

Inasmuch  as  the  relations  of  the  foregoing  fissures  to  all  the  intracranial 
areas  now  open  to  surgical  approach  can  be  definitely  determined,  any  further 
elucidation  in  this  direction  is  not  necessary.  The  ability  to  fix  the  seat  of 
operation  by  cranio-cerebral  topography  only  leaves  for  consideration  the 

technique  of  opera- 
tive procedure. 

The  Prepara- 
tion of  the  Patient. 
— The  administra- 
tion of  bromides 
for  a  week  or  so  be- 
fore the  operation 
and  of  morphin  or 
ergot  a  short  time 
before,  is  sometimes 
practiced  with  the 
belief  that  both  ce- 
rebral vascularity 
and  excitability  are 
lessened  by  these 
means.  Certainly 
a  judicious  use  of 
these  agents  can 
do  no  harm,  and 
they  are  likely  to  do 
good.  The  bowels 
should  be  moved 
freely  the  night  be- 
fore the  operation, 
and  light  diet  only  should  precede  it  and  at  a  proper  interval.  The  pa- 
tient's scalp  should  be  closely  shaved,  scrubbed,  disinfected  thoroughly, 
and  surrounded  with  antiseptic  gauze  bound  firmly  in  place  with  antiseptic 
bandages  on  the  day  before  the  operation,  if  possible.  Before  the  admin- 
istration of  the  anaesthetic  the  situation  of  important  fissures  and  the  pro- 


FiG.  388. — Lucas-Championniere's  Lines. 

A  B.  Horizontal  line  extending  from  outer  angle  of  orbit  (two 
and  four  fifths  inches  long).  B  C.  Line  extending  upward  to 
lower  end  of  central  fissure  (one  and  a  fifth  inches  long).  D. 
Upper  end  central  fissure  (half  inch  behind  mid-sagittal  point). 
C  D.  Course  of  central  fissure.  1.  Speech  center.  2,  3,  and 
4.  Centers  of  arm,  leg,  and  face  respectively. 


OPERATIONS   ON  THE  NERVOUS  SYSTEM.  251 

posed  seat  of  the  operative  attack  should  be  indicated  on  the  scalp  with  tinc- 
ture of  iodine,  an  aniline  pencil,  fine  cautery  lines,  or  by  other  suitable  agents. 
Put  the  patient  on  the  operating  table,  with  the  head  elevated,  exposed  to  a 
good  light  and  placed  on  a  firm  support  covered  with  an  antiseptic  rubber 
sheet.  Chloroform  is  the  preferable  anaesthetic  in  these  cases,  because  the 
administration  is  followed  by  a  minimum  of  cerebral  congestion  and  excite- 
ment. Morphin  should  be  given  more  cautiously  with  chloroform  anaesthesia 
than  with  that  of  ether.  The  markings  on  the  scalp  should  be  made  indelible 
with  delicate  actual  cautery  lines,  and  the  cranial  surface  beneath  them  vig- 
orously punctured  at  frequent  intervals  of  their  course  by  a  sharp-pointed 
instrument.  If  these  precautions  be  not  taken,  the  final  scrubbing  of  the 
scalp  will  blur  or  erase  the  markings  before  their  presence  can  be  utilized, 
and  the  elevation  of  the  scalp  flap  will  expose  an  unmarked  surface  beneath 
on  which  the  seat  of  operation  can  not  then  be  satisfactorily  traced.  The 
author  has  not  infrequently  driven  through  the  scalp  into  the  skull  at  the 
proper  places  short,  sharp,  headless  steel  brads,  to  indicate  the  site  of  oper- 
ation. The  scalp  slips  over  them  readily,  and  they  are  left  standing  firmly 
fixed  in  the  skull.  The  final  cleansing  of  the  scalp,  the  placing  of  the  anti- 
septic towels  around  the  head,  the  arrangement  of  the  assistants,  instru- 
ments, etc.,  should  be  completed  by  the  time  the  patient  is  properly  anaes- 
thetized, in  order  to  avoid  unnecessary  delay,  as  promptness  of  action  in 
these  cases  is  an  important  element  of  success. 

The  Operation  of  Craniotomy  for  Cerebral  TumoT.—Make  a  skin  flap  of 
large  size,  horseshoe  shape,  luith  the  dase  so  formed  and  directed  as  to  afford 
good  drainage  of  the  tuound,  proper  vitality  of  the  flap,  and  comjjlete  oppor- 
tunity for  the  scrutiny  and  technique  of  the  surgeon. 

The  flap  should  be  of  sufficient  size  to  permit  the  removal  of  an  ample 
amount  of  the  cranial  bone  without  undue  encroachment  on  the  soft  parts. 
The  hgemorrhage  attending  the  formation  of  the  flap  is  profuse  and  persist- 
ent, owing  to  the  great   vascularity  and  peculiar  structure  of  the  scalp. 
While  the  loss  of  blood  can  be  limited  somewhat  by  elastic  circular  constric- 
tion and  by  acupressure,  still  it  is  controlled  best  by  prompt  digital  and  in- 
strumental pressure.     Serre-fines  (Fig.  265,  0),  forcipressure,  bulldog  and 
T-shaped  forceps  are  interchangeably  employed  for  the  arrest  of  ha?mor- 
rhage.     In  any  event  the  bleeding  points  are  controlled  as  fast  as  they 
appear,  and  are  tied  thereafter  when  it  suits  best  the  desire  of  the  operator. 
The  periosteum  covering  the  portions  of  bone  to  be  removed  is  reflected 
by  a  crucial  incision,  and  may  thereafter  be  replaced  or  cut  away  according 
to  the  demands  of  proper  drainage  and  closure  of  the  wound.    The  desired 
amount  of  bone  is  removed  by  repeated  applications  of  a  large-sized  trephine, 
supplemented  by  those  of  the  rongeur  or  chisel.     The  forming  and  turning 
aside — wither  without  raising  the  superimposed  soft  parts — of  a  beveled-bor- 
dered  =i-shaped  bone  flap  with  the  saw,  or  of  a  ^-formed  one  in  the  manner 
devised  by  Hartley  (Fig.  318),  can  be  done  if  practicable.    However,  separa- 
tion of  the  dura  from  the  bone  by  means  of  a  spatula  (0  or  dural  separators 
(Fig.  290,  /,  g)  should  precede  the  use  of  the  saw.    Ha>morrhage  from  the 
bone  is  arrested  by  pressure  with  antiseptic  gauze  or  sponge;  by  plugging 


252 


OPERATIVE  SURGERY. 


"1 


Fig.  290. — Instruments  used  in  operations  for  brain  tumor. 
a.  Scalpels,     h,  c.  Large  trephines,     d,  e.  Bone-cutting  forceps.    /,  g.  Horsley's  dural 
separators,    h.  Tenaculum,    i.  Flexible  spatula,    k,  I.  Flexible  retractors,     to.  Curved 
probe-pointed  scissors,    n.  Probe,     o.  Scoop.     P,  Q.  Mouse-tooth  forceps  and  grooved 
director.     B.  Silver  teaspoon.     Fine  curved  needles. 

the  bleeding  point  with  catgut  or  a  bit  of  aseptic  wool;  by  means  of 
actual  cautery,  or  by  crushing  together  the  tables  of  the  skull  with  a 
strong  forceps  at  the   seat  of  hemorrhage.      The  manner  of  division  of 


OPERATIONS   ON  THE   NEliVOUS  SYSTE:\r.  253 

tlie  dura  mater  and  the  control  of  hasniorrliage  arc  described  elsewhere 
(page  241).    Horsley's  wax  may  be  applied  to  the  bleeding  point  (page  5G8). 

Fashion  and  pull  aside  the  dural  flap  and  observe  the  cerehral  character- 
istics. In  making  the  flap  insert  a  small  tenaculum  (Fig.  290,  h)  into  the 
dura  at  the  most  dependent  part — if  consistent  with  the  vascular  integrity  of 
the  flap — al)out  a  quarter  of  an  inch  from  the  border  of  the  bone.  Raise  the 
dura  from  off  the  brain  and  make  a  small  incision  through  it  with  the  point 
of  a  scalpel.  Introduce  through  the  opening  the  blade  of  a  small,  curved, 
l)lunt-pointed  scissors  (Fig.  290,  m),  and  divide  the  membrane  equally  at 
either  side  of  the  tenaculum  a  quarter  of  an  inch  from  the  bone  for  four 
fifths  of  the  entire  circumference  of  the  opening,  if  this  amount  of  space  be 
needed,  and  the  nutrition  of  the  flap  be  not  imperiled.  If  the  membranes  be 
cedematous,  congested,  or  adherent ;  if  the  brain  bulge  into  the  opening  and 
its  pulsations  be  feeble  or  absent,  its  structure  unduly  firm  and  the  convolu- 
tions flattened,  intracranial  pressure  is  indicated  and  the  morbid  process  will 
be  in  sight  or  near  to  hand.  Further  exploration  of  the  brain  can  be  made 
by  puncturing  it  with  a  small  probe,  a  hyj)odermic  needle,  or  by  free  incision 
with  a  bistoury.  Punctures  and  incisions  of  the  brain  should  begin  at  the 
apex  of  a  convolution  and  be  continued  in  the  direction  of  the  commissural 
fibers,  not  dividing  but  separating  them  as  much  as  possible,  thus  preserving 
their  function.  Exploration  with  needles  and  probes  is  often  quite  unneces- 
sary, even  useless,  and  perhaps  dangerous.  Unnecessary  when  the  solidity 
of  the  tumor  permits  the  finger  to  determine  its  presence ;  useless  when  the 
growth  is  so  soft  that  touch  can  not  detect  its  existence,  and  dangerous  from 
the  liability  of  the  wounding  of  vessels,  ganglionic  centers,  etc.  Therefore 
the  educated  finger  is  the 
best  means  of  exploration 
and  can  be  safely  intro- 
duced an  inch  or  more 
beneath    the    skull    and  Fig.  291.— Keen's  electrode, 

carried  around  the  bor- 
ders of  the  opening  for  this  purpose.  The  employment  of  the  faradaic  cur- 
rent by  means  of  the  electrode  (Fig.  291)  devised  for  the  purpose  of  stimu- 
lating the  motor  centers  with  which  it  is  brought  in  contact,  to  indicate  the 
relations  of  the  resultant  movements  to  the  seat  of  the  disease,  and  also  the 
degree  of  excitability  of  the  diseased  center,  is  a  commendable  practice. 

These  manifestations,  while  both  interesting  and  instructive,  bear  no 
necessary  association  with  an  operation  not  directed  to  the  removal  of  a 
motor  center. 

Divide  the  pia  ifi  the  lo/ig  axis  of  the  tiimor  if  jjossible  and  carefully 
draio  it  aside. 

The  hgemorrhage  arising  from  a  division  of  the  pia  can  be  reduced  to 
a  minimum  by  raising  the  membrane  from  the  sulci  and  surface  carefully 
and  drawing  it  aside,  or  by  ligature  en  masse.  If  drawn  aside,  it  can  be 
returned  to  the  original  site  if  circumstances  will  permit.  The  treatment 
of  the  tumor  depends  on  the  etivironment,  etc.  If  the  tumor  be  in  view 
and  encapsulated,  it  should  be  enucleated  with  the  curved  blunt-pointed 


254  OPERATIVE  SURGERY. 

scissors  or  a  spatula,  aided  by  the  finger  of  the  operator.  If  it  be  not 
encapsulated,  it  may  be  if  desirable  removed  with  a  knife,  sharp  scoop,  or 
a  spoon  (o,  R,  Fig.  290).  If  the  tumor  be  located  beneath  the  brain  surface, 
a  free  incision  is  made  down  upon  it  and  the  wound  borders  held  apart 
with  retractors  while  the  tumor  is  enucleated  or  cut  away  as  before.  The 
cavity  in  the  brain  caused  by  the  removal  of  the  tumor  should  be  lightly 
packed  with  a  single  long  narrow  strip  of  iodoform  gauze  cleared  of 
loose  threads,  and  so  placed  at  the  bottom  and  sides  of  the  cavity  that  it  can 
be  removed  gradually  or  promptly  without  hindrance.  A  cystic  tumor  of 
the  surface  is  dissected  away  when  possible;  if  not  advisable,  the  superficial 
portion  is  removed,  the  interior  cauterized  with  nitrate  of  silver  and  packed 
with  gauze;  if  beneath  the  surface  of  the  brain,  it  is  opened,  cauterized,  and 
packed  as  before ;  when  of  unusual  size,  of  indefinite  outline  and  association, 
it  can  be  tapped,  drained  with  horsehair  or  catgut,  and  lightly  packed  with 
long  strips  of  gauze.    Pure  carbolic  acid  followed  by  alcohol  is  useful. 

In  all  instances  of  packing,  the  gauze  should  be  so  introduced  that  it 
can  be  removed  slowly  and  at  intervals  to  avoid  any  undue  disturbance  of 
the  brain.  If  packing  of  the  wound  be  dispensed  with,  the  dural  opening 
should  be  closed  with  fine  catgut,  leaving  an  opening  at  the  most  dependent 
part  through  which  horsehair,  a  strip  of  gauze,  or  of  lightly  rolled  rubber 
tissue  is  introduced  for  drainage  purposes.  If  the  brain  wound  be  packed 
with  gauze,  the  sewing  of  the  dura- is  limited  to  the  proper  accommodation 
of  the  protruding  gauze  and  its  subsequent  withdrawal.  The  scalp,  like  the 
dura,  is  closed  in  conformity  with  the  demands  of  drainage,  silkworm  gut 
being  employed  for  the  purpose  in  this  instance.  After  a  final  cleansing, 
the  wound  ia  covered  with  rubber  tissue,  upon  which  is  placed  in  turn  layers 
of  aseptic  gauze,  loose  gauze,  and  aseptic  cotton,  all  of  which  is  held  in  posi- 
tion with  antiseptic  bandages. 

Horsley  and  Maceiven  divide  the  operation  into  two  stages  to  avoid  the 
ill  effects  of  the  shock  so  often  due  to  continuous  effort.  In  the  first  stage 
the  dura  is  exposed  and  the  wound  packed  with  gauze.  In  the  second 
stage — some  days  later — the  operation  is  completed. 

The  Precautions. — The  strong  tendency  of  brain  matter  to  escape  and  to 
the  development  of  hernia  cerebri  requires  that  the  gray  matter  be  disturbed 
as  little  as  possible,  that  infection  be  prevented,  and  that  the  opening  of  the 
dura  be  promptly  and  securely  closed.  If  the  proper  sewing  of  the  mem- 
brane be  opposed  by  brain  pressure,  it  should  be  restrained  if  practicable  by 
counter  pressure  with  a  single  broad  or  two  narrow  spatulae  until  the  sew- 
ing is  completed.  If  two  narrow  spatulse  be  passed  beneath  the  dura,  while 
lying  on  each  other,  and  separated,  like  the  blades  of  scissors,  the  area  of  re- 
sistance will  be  correspondingly  decreased ;  a  manifest  advantage  is  thus 
gained  in  aid  of  the  complete  closure  of  the  membrane.  If  it  be  impracti- 
cable to  close  the  gap  in  the  dura  with  stitches,  the  advisability  of  restraining 
further  escape  by  means  of  a  thin  celluloid  plate  placed  in  contact  with  the 
opening  in  the  dura  and  so  fitted  to  the  divided  borders  of  the  skull  as  to 
prevent  farther  protrusion,  should  be  considered.  If  brain  have  escaped 
already  beyond  the  opening  in  the  skull  further  advance  may  be  prevented 


OPERATIONS   ON   THE  NERVOUS   SYSTEM.  255 

by  the  application  to  it  of  a  closely  fitting  metallic  cover  confined  in  place 
with  straps.  The  shaving  off  of  the  protrnding  brain  should  be  regarded 
as  an  after  and  final  step  rather  than  as  an  early  and  unavoidable  one, 
especially  when  the  portions  to  be  removed  possess  functional  activity  and 
have  not  yet  been  subjected  to  repressive  influences.  Not  long  since  the 
author  in  a  case  of  threatening  protrusion  following  immediately  the  removal 
of  a  cicatrix  from  the  brain  and  dura  applied  a  thin  celluloid  plate  at  once 
to  the  lesion  in  the  manner  described  (see  page  356),  with  a  successful  out- 
come so  far  as  the  control  of  the  tendency  to  protrusion  was  concerned.  If 
the  electrode  (Fig.  291)  he  used,  it  is  important  to  recall  that,  1,  a  strong 
current  burns  the  cortex,  and  that  one  of  a  strength  to  cause  contraction 
of  the  thenar  muscle  is  sufficient  for  the  test ;  2,  that  antiseptics,  especially 
bichloride  in  solution,  prevent  electric  reaction,  and  that  sterilized  water  is 
the  best  agent  for  use  at  this  time ;  3,  that  not  infrequently  the  reaction  can 
be  excited  if  the  electrode  be  applied  to  the  uncut  dura,  and  that  this  fact 
is  important  as  the  brain  substance  is  not  then  exposed ;  and,  4,  that  the 
electrode  should  be  thoroughly  aseptic  when  applied  to  the  brain. 

The  Results. — The  results  of  operation  for  brain  tumor  depend  on  the  sit- 
uation, the  depth,  the  nature,  and  environment  of  the  growth.  Encapsulated, 
non-malignant,  and  superficial  cerebral  tumors  are  the  most  favorable  for 
operation.  Infiltrating  tumors  are  of  bad  prognosis  on  account  of  the  loss 
of  brain  and  blood  attending  the  removal,  and  the  frequent  and  prompt  re- 
turn of  the  growth.  Cystic  growths  offer  a  fair  prognosis  if  they  be  excised, 
or  be  treated  by  caustic,  or  drainage  and  packing.  The  bare  emptying  of  the 
cyst  and  closure  of  the  wound  is  useless,  as  it  rapidly  refills.  The  prompter 
the  operation  the  better  the  prognosis  will  be  in  all  cases. 

Total  Results  of  Operation  for  Brain  Tumor  (Starr). 

Total. 


Cere- 

Cere- 

bral. 

bellar. 

81 

16 

26 

9 

1 

2 

39 

3 

15 

2 

Total  number  of  eases  operated  on 81  16  97 

Cases  in  which  tumor  was  found. . .    26  9  35 

Cases  in  which  tumor  was  found  but  not  removed 1  2  3 

Cases  in  which  tumor  was  removed  and  patient  recovered 39  3  42 

Cases  in  which  tumor  was  removed  and  patient  died 15  2  17 

Somewhat  later  Starr  reports  two  hundred  and  twenty  similar  operations, 
in  seventy-three  of  which  the  tumors  could  not  be  found,  and  in  seven 
could  not  be  removed.  The  death  rate  for  removal  of  the  remaining  one 
hundred  and  forty  cases  was  +  34:  per  cent,  which  is  no  doubt  much  too 
small  to  represent  the  outcome  of  all  cases  operated  on,  as  many  indeed  are 
not  reported.  McCosh  believes  that  seventy-five  per  cent  is  much  nearer 
the  true  figure. 

Craniotomy  for  Cerebellar  Tumor.— Owing  to  the  diflaculty  of  diagnosti- 
cating the  exact  situation  of  a  cerebellar  tumor,  a  surgical  operation  for  the 
patient's  relief  is  largely  of  an  exploratory  character.  The  differences  in 
the  technique  of  this  and  the  operations  for  cerebral  tumor  consist  in  the 


256  OPERATIVE  SURGERY. 

formation  of  the  flap  and  the  entrance  to  the  cranial  cavity.  In  other  re- 
spects their  technique  is  substantially  similar.  The  flap  of  the  soft  jjarts  is 
limited  above  by  the  upper  border  of  the  superior  curved  line  of  the  occipital 
bone,  below  it  terminates  opposite  the  second  cervical  vertebra,  the  median 
line  of  the  head  limits  the  inner  border,  and  the  posterior  margin  of  the  mas- 
toid process  the  outer.  It  is  horseshoe  shaped,  and  the  incision  forming  it 
is  carried  down  to  the  bone.  The  flap  is  reflected,  the  periosteum  remaining 
undisturbed  except  at  the  area  of  entrance  to  the  cranium;  here  the  mem- 
brane is  turned  aside  before  division  of  the  skull  is  made.  The  opening 
through  the  shull  is  formed  with  a  chisel  and  mallet,  is  about  two  inches 
in  diameter,  and  may  be  increased  thereafter  by  a  rongeur  (d,  e,  Fig.  290) 
as  circumstances  demand.  On  account  of  the  thinness  of  the  bone  at  this 
situation  the  surgeon  must  exercise  great  care.  The  dura  is  divided,  the 
cerebellum  explored  with  the  finger  or  aspirator,  etc.,  and  the  tumor  ma- 
nipulated as  in  cerebral  cases.  The  deep  soft  parts  are  united  with  catgut 
independently  of  the  main  flap,  which  is  sewed  with  silkworm  gut  after 
necessary  drainage  is  provided.  The  usual  antiseptic  dressings  are  bound  in 
place  with  gauze  bandages. 

The  Precautions. — As  before  remarked,  the  bone  at  the  site  of  operation 
is  very  thin  and  devoid  of  diploeic  structure,  hence  thoughtless  use  of  force 
is  likely  to  injure  the  soft  parts  beneath.  The  lateral  {A,  B,  Fig.  292)  and 
occipital  sinuses  may  be  invaded  if  the  crest  and  superior  curved  lines  be  en- 
croached upon  in  opening  the  skull.  Care  must  be  taken  not  to  disturb  the 
middle  lobe  of  the  cerebellum,  unless  the  removal  of  the  tumor  requires  that 
it  be  done. 

The  Results. — The  results  of  the  operation  for  the  removal  of  these 
growths  are  registered  already  under  the  preceding  topic. 

Craniotomy  for  Epilepsy, — When  the  motor  center  primarily  involved  in 
the  epileptic  convulsion  can  be  determined,  or  when  the  disease  has  been 
preceded  by  a  head  injury  that  is  manifest,  craniotomy  is  often  performed, 
and  usually  with  a  large-sized  trephine.  The  electrode  plays  an  important 
part  in  these  cases,  as  it  often  serves  to  locate  the  center  primarily  affected. 
The  technique  of  the  use  of  the  trephine  and  of  the  removal  from  the  brain 
and  its  membranes  of  a  morbid  exciting  cause  has  already  been  sufficiently 
discussed.  The  scalp  flap  should  be  large  enough  to  afford  a  broad  margin 
between  its  borders  and  those  of  the  bone  opening,  in  order  that  the  healing 
of  each  may  be  entirely  independent  of  the  other.  Primary  union  of  the 
entire  wound  should  be  sought  for  as  the  cicatrization  following  delayed 
union  may  become  a  provoking  element  in  the  production  of  convulsions 
thereafter.  The  introducing  into  the  cranial  opening  and  placing  on  the 
freshened  surface,  of  a  metallic  substance,  of  gutta-percha,  or  of  rubber 
tissue,  celluloid,  decalcified  bone  plate,  etc.,  for  the  purpose  of  preventing  or 
limiting  cicatricial  action,  is  advised  in  those  cases  where  the  irritation  is 
thought  to  have  arisen  from  the  influence  of  previous  cicatricial  contraction. 

In  the  opinion  of  the  author,  the  stable  qualities  of  thin  celluloid  plate 
(tw  inch)  establish  its  worth  for  this  purpose  above  that  of  other  foreign 
substances  of  a  simple  nature.    Harris  commends  highly  silver  foil. 


OPERxVTIONS  ON   THE   NERVOUS   SYSTEM.  257 

Gold-leaf,  gutta-porclia,  and  rid^hcr  tissues  are  placed  in  contact  with  the 
pia,  the  edges  underlying  somewhat  those  of  the  cranial  opening,  to  prevent 
extending  cicatrization.  These  substances,  however,  are  not  trustworthy, 
as  they  often  become  disarranged  and  disintegrated  by  the  vital  influences 
to  which  they  are  subjected.  A  reliable  substance  for  this  purpose  is  a  great 
desideratum. 

If,  after  the  removal  of  the  bone,  a  small  cut  be  made  through  the  dura 
and  a  silver  probe  properly  curved  be  passed  through  the  opening  and  be- 
neath it,  and  swept  around,  the  near-to-hand  adhesions  can  often  be  deter- 
mined. The  removal  from  the  brain  of  a  cicatrix  or  motor  center  for  relief 
from  epilepsy  is  rarely  followed  by  cure,  since  the  repair  of  the  wound  pro- 
duces a  cicatrix  which,  later,  usually  causes  the  convulsions  to  recur. 

The  Remarks. — No  patient  should  be  operated  on  unless  the  attacks  have 
been  scrutinized  as  to  the  part  first  affected  and  the  order  of  advance  of 
the  convulsion  by  one  competent  to  make  the  observations.  The  statements 
of  relative  and  of»  sympathetic  and  ignorant  observers  can  not  be  relied  on 
in  these  cases.  A  motor  center  is  removed  cautiously  in  the  direction  of  the 
fibers  (page  253)  with  knife  or  scissors,  and  the  removal  should  be  complete, 
or  the  attempt  at  cure  will  be  useless.  If  the  condition  of  the  membrane 
will  permit,  the  pia  should  be  raised  up  and  pushed  aside,  rather  than  torn 
or  cut ;  thus  ha3morrhage  will  be  lessened,  and  then,  if  advisable,  the  mem- 
brane can  be  replaced.  The  bleeding  from  large  vessels  of  the  pia  can  be 
controlled  if  the  vessels  be  tied  independently  in  two  situations  with  fine 
catgut  ligatures  passed  around  them  by  the  aid  of  a  needle,  and  cut  between 
the  points  of  tying. 

The  Results. — The  procedure  itself  is  not  devoid  of  danger  by  any  means, 
and  the  results  of  operations  for  the  Jacksonian,  focal,  and  long-standing  trau- 
matic varieties  of  this  disease  are  almost  invariably  followed  by  grievous  dis- 
appointment. It  is  difficult,  indeed,  to  say  as  yet  whether  the  removal  of  a 
motor  center  of  the  brain  for  the  cure  of  epilepsy  is  justified  by  any  other  fact 
than  that  of  the  sad  hopelessness  of  the  case.  Operation  for  traumatic  epi- 
lepsy offers  better  results  than  in  other  forms,  especially  if  performed  before 
the  development  of  the  convulsion  habit  that  too  often  complicates  the  cases 
of  long  standing.  As  a  whole,  the  results  from  operative  procedures  in  the 
latter  variety  of  cases  may  be  regarded  as  c|uite  satisfactory.  However,  those 
reports  announcing  a  cure  of  fifty  per  cent  should  be  accepted  with  great  re- 
serve, as  much  time  should  elapse  before  the  final  estimate  of  a  case  is  made. 

Craniotomy  for  the  Evacuation  of  Pus. — A  knowledge  of  the  presence 
and  situation  of  abscess  following  injury  of  the  cranium  is  based  on  the 
facts  of  the  location  of  the  injury,  the  local  and  constitutional  symp- 
toms of  inflammation  and  suppuration,  and  the  later  development  of  the 
symptoms  of  cerebral  compression.  The  proper  site  for  operation  in  trau- 
matic abscess  is  over  the  ai'ea  of  cerebral  compression  irrespective  of  the 
seat  of  the  injury.  If  hemianopsia  be  the  first  symptom  to  occur,  the  tre- 
phine should  be  applied  over  the  occipital  lobe  involved  in  the  morbid 
manifestation.  If  the  pus  he  hetiveen  the  dura  and  cranium.,  the  removal  of 
a  button  of  bone  affords  a  prompt  discharge  of  the  fluid  and  relief  to  the 


258  OPEEATIVE  SURGERY. 

patient  unless  pyemia  complicates  the  recovery.  The  pus  cavity  should  be 
thoroughly  flushed  with  a  five-per-cent  solution  of  carbolic  acid,  loosely 
packed  with  iodoform  gauze,  and  covered  with  a  moist  antiseptic  dress- 
ing. If  the  pus  he  not  found  at  tliis  situation,  raise  a  flap  of  dura  and 
explore  the  brain  with  an  aspirator,  passing  the  needle  in  various  directions 
until  pus  is  found,  being  careful  to  withdraw  the  needle  and  insert  it  at  a 
different  point  each  time  the  direction  is  changed.  If  pus  be  found  deep 
in  the  brain,  the  needle  should  be  left  in  position  as  a  guide  to  the  puru- 
lent collection.  If  the  pus  be  superficially  located,  the  needle  is  with- 
drawn. Before  evacuation  of  the  pus  the  diploeic  structure  should  be  pro- 
tected from  the  danger  of  infection  by  smearing  it  Avith  a  compound  of 
glycerin  and  iodoform  or  some  other  antiseptic  mixture.  The  pus  is  then 
liberated  directly  or  by  careful  separation  of  the  brain  along  the  course  of 
the  needle  with  a  grooved  director  or  dressing  forceps.  The  liberation  of 
the  pus  is  quickly  followed  by  the  introduction  into  the  abscess  cavity  of  a 
double-barreled  drainage  agent  formed  by  placing  two  small  soft  drainage 
tubes  parallel  with  each  other  and  fastening  them  together.  The  cavity  can 
then  be  quickly  washed  out  through  one  tube  by  pouring  through  the  other 
a  gentle  stream  of  warm  sterilized  water  or  a  boric-acid  solution.  The  tubes 
are  fastened  in  position  with  a  large  safety  pin  to  prevent  their  further  en- 
trance into  the  cavity.  The  wound  is  then  packed  loosely  a  little  beyond  and 
around  the  tubes  with  iodoform  gauze,  the  whole  covered  lightly  with  anti- 
septic gauze  and  confined  in  place  with  gauze  bandages.  If  the  discharge 
be  free,  at  the  next  dressing  one  tube  can  be  removed  and  the  other  short- 
ened if  necessary.  The  wound  is  dressed  once  or  twice  daily  to  insure  free 
drainage,  the  remaining  tube  being  shortened  from  time  to  time  to  keep  pace 
with  the  closure  of  the  cavity.  Two  or  three  weeks  are  sometimes  required 
to  effect  this  process.  The  opening  in  the  dura  and  the  scalp  should  be 
closed  as  soon  as  possible  to  avoid  the  formation  of  hernia  cerebri. 

Cerebral  abscess  is  usually  a  sequel  of  otitis  media  and  of  suppurative 
processes  of  the  orbital  and  nasal  cavities.  About  half  of  all  cases  of  cere- 
bral abscess  of  either  the  acute  or  chronic  form  are  due  to  otitis  media.  Ab- 
scess also  develops  in  the  cerebellum  as  the  result  of  this  disease.  The  com- 
parative rate  of  occurrence  is  about  four  in  the  temporo-sphenoidal  lobe  of 
the  cerebrum  to  one  in  the  cerebellum,  and  much  more  often  at  the  right 
than  the  left  side  of  the  cerebrum.  Earely  do  they  appear  in  the  pons  and 
crura  cerebri.  Abscess  from  this  cause  often  develops  insidiously,  and  the 
diagnosis  is  frequently  obscure  and  delayed.  Cerebral  abscess  may  be  con- 
founded at  first  with  sinus  thrombosis  or  meningitis,  either  of  which  is  as 
frequent  a  sequel  of  otitis  media  as  is  abscess. 

The  Operation  for  Cerebral  Abscess. — Shave  and  scrub  the  scalp;  draw 
Reid's  base  line ;  indicate  on  the  scalp  a  point  located  an  inch  and  a  quarter 
above  and  the  same  distance  behind  the  center  of  the  meatus.  At  this 
point,  according  to  Barker,  a  space  three  quarters  of  an  inch  in  diameter 
corresponds  to  the  location  of  nine  tenths  of  the  abscesses  of  the  temporo- 
sphenoidal  lobe.  Birmingham  adds  half  an  inch  to  the  perpendicular  line 
to  avoid  more  certainly  the  lateral  sinus  (Fig.  292).    The  technique  is  simi- 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


259 


lar  here  to  that  for  abscess  elsewhere  in  the  brain,  until  after  the  button  is 
removed.  Then  place  the  finger  lightly  on  the  dura.  If  pulsation  be  absent 
or  feeble,  the  presence  of  abscess  is  indicated,  especially  in  the  absence  of  a 
depressed  circulation.  Open  the  dura  sufficiently  to  expose  the  brain  surface, 
and  if  pus  be  not  seen  introduce  a  good-sized  aspirating  needle  inward,  for- 
ward, and  downward  toward  the  apex  of  the  jjetrous  bone,  about  two  inches. 
The  pus  in  these  cases  is  usually  too  thick  to  pass  through  other  than  a  fair- 


FiG.  293. — Diagram  of  adult  skull,  illustrating  various  points  for  craniotomy. 

Horizontal  measurements  are  made  from  the  centers  of  the  auditory  meatus  along  Reid's 
base  line,  R  R.  Vertical  measurements  meet  this  line  at  a  right  angle.  A.  Sigmoid 
portion  of  lateral  sinus,  a  point  on  the  base  line  three  quarters  of  an  inch  from  the 
center  of  the  meatus.  B.  Transverse  portion  of  the  sinus,  a  point  an  inch  behind  the 
meatus  and  a  quarter  of  an  inch  above  the  base  line.  C.  Mastoid  antrum,  the  point 
of  meeting  of  a  line  drawn  along  the  upper  wall  of  the  meatus  parallel  with  the  base 
line,  and  one  drawn  at  the  posterior  wall  at  right  angles  with  the  base  line.  D.  A 
point  for  cerebral  abscess  (temporo-sphenoidal),  three  quarters  of  an  inch  above  the 
base  line  at  posterior  border  of  meatus.  E.  A  point  for  cerebellar  abscess,  an  inch 
and  a  half  behind  the  meatus  and  a  quarter  of  an  inch  below  the  base  line.  F.  A 
point  for  anterior  branch  of  middle  meningeal,  at  an  inch  and  a  half  behind  external 
angular  process  of  frontal  bone  and  the  same  distance  above  zygoma.  G.  A  point 
for  posterior  branch  of  middle  meningeal,  one  inch  and  three  quarters  behind  ex- 
ternal angular  process  and  a  quarter  of  an  inch  above  zygoma.  H.  A  point  for  tap- 
ping the  lateral  ventricle,  an  inch  and  a  half  above  center  of  meatus. 

Note. — It  will  be  noted  that  some  of  the  measurements  indicated  above  vary  consider- 
ably from  those  of  the  text,  but  inasmuch  as  all  are  the  outcome  of  extended  experi- 
ence and  observation  of  competent  men,  it  is  difficult  indeed,  even  if  wise,  to  express 
a  decided  preference.  If  either  prove  unsatisfactory,  another  should  be  tried,  using 
the  trephine  again,  or  extending  the  primary  opening  with  the  rongeur.  The  illus- 
tration (Pig.  293)  can  be  utilized  for  other  measurements  than  those  stated  in  the 
description,  and  with  equal  facility  and  exactness. 


sized  needle  ;  for  this  reason  the  use  of  ordinary  hypodermatic  needles  should 
be  discouraged.  Failing  to  find  pus  with  the  first  insertion,  the  effort  is 
repeated  in  different  directions  as  described  on  the  preceding  page.  If  pus  be 
not  found  thus,  the  presumption  should  be  that  it  is  not  present.     However, 


260  OPERATIVE  SURGERY. 

if  the  evidence  of  intracranial  pressure,  as  indicated  by  flattened  convolu- 
tions, congested  vessels,  marked  protrusion  of  the  brain  into  the  opening, 
modified  pulsation,  etc.,  be  noted,  a  needle  of  larger  caliber  should  be  intro- 
duced ere  the  procedure  is  relinquished.  If  pus  be  found,  the  manner  of 
evacuating,  draining,  and  the  subsequent  treatment  of  the  abscess  and  wound 
are  the  same  as  already  described.  The  fact  that  these  abscesses  are  due 
to  direct  infection  and  contain  foul  and  offensive  pus  should  stimulate  at- 
tention in  the  highest  degree  to  antiseptic  care.  Frequent  washing  out 
of  the  abscess  cavity  with  Thiersch's  fluid  is  required  "for  some  time  if  the 
offensive  discharge  continues. 

The  anterior  surface  of  the  petrous  portion  of  the  temporal  bone,  roof  of 
the  tympanum,  and  the  petro-squamous  fissure  can  be  examined  for  abscess 
through  a  half-inch  opening  located  directly  above  the  external  meatus  seven 
eighths  of  an  inch.  Through  this  opening  the  entire  anterior  surface  of  the 
petrous  bone  can  be  explored  by  passing  a  small  probe  cautiously  along 
between  the  dura  and  the  bone.  If  pus  be  found,  it  should  be  liberated  and 
the  pus  cavity  thoroughly  drained.  If  necrosed  bone  is  present,  it  should 
be  removed  if  loose ;  if  not,  thorough  drainage  and  cleanliness  should  be 
established  until  the  diseased  bone  comes  away  or  is  removed,  after  which 
the  wound  is  treated  in  the  manner  usual  in  cases  of  this  nature. 

The  Precautions. — If  the  needle  be  inserted  too  far,  the  basal  ganglia  may 
be  injured ;  if  misdirected  and  carried  too  far,  the  petrosal  sinuses  may  be  en- 
tered. The  use  of  a  needle  of  small  caliber  is  unresponsive  and  therefore 
undecisive  and  deceptive.  However,  if  the  aspiration  be  negative,  the  exam- 
ination of  the  contents  of  the  lumen  of  the  needle  with  a  microscope  may 
disclose  the  presence  of  pus.  A  small  opening  only  should  be  made  in  the 
dura  before  the  detection  of  pus,  for  if  pus  be  not  found,  the  opening  can  be 
easily  closed.  The  oval  flap  of  the  dura  should  be  made  after  pus  is  found 
and  in  the  manner  before  described  (page  253).  Great  cleanliness  and  care 
are  necessary  to  prevent  secondary  meningitis  from  purulent  contact. 

Cerebellar  abscess  from  otitis  media  can  be  reached  through  a  half-inch 
opening  in  the  cranium  made  either  at  a  point  an  inch  and  a  half  behind 
and  a  quarter  of  an  inch  below  the  center  of  the  meatus  (Fig.  393, E),  or  two 
inches  behind  and  an  inch  below  this  opening  (Birmingham),  to  avoid  the 
occipital  artery.  At  the  former  place  the  anterior  border  of  the  trephine 
rests  directly  behind  the  posterior  border  of  the  mastoid  foramen.  An  escape 
of  pus  from  the  mastoid  foramen,  due  to  lateral  sinus  involvement,  should  be 
looked  for  at  the  time,  since  a  diseased  sinus  may  be  mistaken  for  a  cere- 
bellar abscess. 

The  Results. — The  insidious  development,  the  late  recognition,  and  the 
persistency  of  the  exciting  cause  in  abscess  of  the  brain  invest  the  outcome 
with  a  somber  hue.  The  death  rate  from  all  causes  after  operation  is  forty 
per  cent.  The  rate  from  abscess  due  to  middle-ear  disease  alone  is  much 
greater  than  this. 

Craniotomy  for  Thrombosis  of  Lateral  Sinus  and  Jugular  Vein.— The 
operative  measures  for  this  condition  are  the  recent  outcome  of  increased 
diagnostic  acumen  and  of  improved  surgical  technique.     The  thrombosis  is 


OPERATIONS  ON   THE   NERVOUS   SYSTEM.  201 

a  sequel  of  otitis  iiiodia,  and  it  happens  quite  as  frequently  as  does  abscess 
of  the  brain.  Inasmuch  as  these  cases  terminate  fatally  if  unaided,  operative 
measures  should  be  prompt  and  decisive. 

The  Operation. — In  the  presence  of  rigid  antiseptic  technique,  carefully 
expose  the  lateral  sinus  through  a  trephine  opening,  three  quarters  of  an 
inch  in  diameter,  the  center  of  which  is  located  a  quarter  of  an  inch  above 
and  an  inch  behind  the  middle  of  the  bony  meatus  (Fig.  292,  B).  This 
opening  can  be  extended  as  circumstances  require  by  aid  of  the  rongeur. 
An  extension  forward  (A,  C)  is  advised,  so  as  to  open  the  sigmoid  portion  of 
the  sinus  and  the  mastoid  antrum  to  permit  removal  of  diseased  tissues. 
Examine  the  sinus  with  the  finger  and  explore  it  with  a  hypodermic  syringe 
also,  if  any  doubt  exists  as  to  a  thrombotic  condition  of  the  vessel.  If 
thrombosed,  it  is  advised  by  some  to  expose  the  internal  jugular  vein  in 
the  neck  and  ligature  it,  to  prevent  the  escape  into  the  circulation  of  loos- 
ened clots  from  the  sinus.  It  is  possible,  however,  for  the  disease  to  ex- 
tend inward  through  the  upper  tributaries  of  the  vein,  in  spite  of  every 
preventive  effort.  Then  open  the  sinus  and  remove  the  thrombi  with  a 
small  scoop  aided  by  antiseptic  douching.  If  severe  hgemorrhage  occurs, 
plug  the  bleeding  point  instantaneously  with  a  strip  of  iodoform  gauze 
already  prepared  for  the  purpose.  If  lijemorrhage  from  the  sinus  is  feared 
on  account  of  incomplete  closure  with  thrombi,  ligature  the  sinus  before 
opening  it.  If  feasible,  the  clots  are  removed  frdin  the  vein  and  sinus  and 
the  lumen  is  cleansed  by  a  through-and-through  stream  of  antiseptic  fluid. 
If  the  thrombi  can  not  be  safely  removed,  the  wounds  are  then  drained  with 
small  rubber  tubes  and  packed  with  iodoform  gauze.  They  should  be 
cleansed  and  dressed  frequently  during  the  course  of  treatment,  especially 
if  thrombi  still  remain  in  the  vessels.  Excision  of  trunk  so  as  to  include 
its  branches  is  practiced. 

The  Precautions. — If  severe  hemorrhage  occurs  from  the  sinus,  apply  a 
tampon  to  the  bleeding  point  and  allow  it  to  remain  for  two  or  three  da3's 
until  further  bleeding  is  obviated.  Be  careful  not  to  shut  into  a  sinus 
or  vein  any  of  the  thrombosed  contents  by  tying  through  a  diseased  point. 
In  the  removal  of  the  central  thrombus,  cleanse  thoroughly  the  parts  as  the 
clot  is  removed,  so  that  the  stopping  of  a  sudden  gush  of  blood  with  the 
tamponade  will  not  push  inward  loose  infecting  agents,  nor  will  the  previous 
site  of  an  infected  clot  provoke  infection  of  one  newly  formed.  If  the  cen- 
tral clot  be  firm  and  inoffensive,  presenting  no  evidence  of  disintegration, 
the  question  of  the  wisdom  of  its  removal  may  properly  arise,  and  it  should 
be  decided  by  the  other  circumstances  that  attend  the  case. 

The  Results. — About  fifty  per  cent  of  cases  recover  with  operation; 
without  it  a  recovery  need  not  be  expected. 

Craniotomy  for  General  Paralysis  of  the  Insane. — The  trephine  has 
been  applied  to  the  parietal  region  and  at  the  seat  of  defined  headache  in 
a  few  instances  with  and  without  opening  the  dura  for  drainage  pur- 
poses to  afford  relief  in  this  condition.  Tapping  the  ventricles  has  been 
practiced  also,  but  little  encouragement  has  resulted  from  either  method  of 

practice. 

19 


262 


OPERATIVE  SURGERY. 


Opening  the  Mastoid  Antrum. — The  mastoid  antrum  is  opened  to  relieve 
it  of  inflammatory  products  that  enter  from  an  inflamed  middle  ear  or 
result  from  inflammation  of  the  antrum  and  mastoid  cells  themselves. 

The  Important  Facts. — In  the  infant^,  the  mastoid  process  is  not  present, 
but  the  mastoid  antrum  is,  and  in  the  form  of  a  cell  communicating  with 
the  middle  ear.  Later  the  mastoid  process  appears  and  the  antrum  becomes 
more  deeply  placed,  until  at  the  age  of  ten  when  the  outer  wall  is  about 
two  fifths  of  an  inch  in  thickness.     At  puberty  numerous  other  cells  are 


Fig.  293. — Instruments  employed  in  operation  on  the  mastoid  antrum. 
a.  Scalpels,     h.  Bone-drill,     c.  Periosteal  elevator,     d.  Small  trephine,     e.  Foreipressure. 
/.  Thumb  forceps,    g.  Long-nosed  rongeur,     h.  Small  scoop,     i,  j,  Jc.  Bone  chisels. 
I.  Mallet,    m.  Scissors,    n.  Fine  probe,     o.  Long  curved  neck  rongeur,     p.  Com- 
mon rongeur,    q.  Gimlet,    r.  Retractors,    s.  Needles. 

present  in  the  process.  In  the  adult  the  area  of  cell  development  is  limited 
below  by  the  masto-occipital  suture ;  anteriorly  it  extends  above  the  meatus, 
and  superiorly  to  within  half  an  inch  of  the  temporo-parietal  suture.  At 
this  time  the  antrum  is  the  size  of  a  pea  and  is  separated  from  the  cranial 
cavity  by  a  wall  one  twenty-fifth  to  six  twenty-fifths  of  an  inch  in  thickness, 
and  from  the  lateral  sinus  and  the  external  surface  of  the  mastoid  process 
by  walls  one  half  to  three  quarters  of  an  inch  in  thickness.  It  now  corre- 
sponds to  a  point  immediately  behind  the  meatus  and  below  the  level  of  its 
upper  border.  The  lateral  sinus  varies  somewhat  in  its  relations  with  the 
mastoid  bone  (Fig.  293).  It  approaches  to  within  one  inch  and  a  half  be- 
hind and  three  quarters  of  an  inch  above  the  center  of  the  bony  meatus,  then 
turns  more  or  less  abruptly  downward  and  passes  one  half  inch  behind  the 


OPERATIONS  OF  THE  NERVOUS  SYSTEM.  263 

external  meatus,  and  runs  to  a  point  one  sixth  to  one  quarter  of  ;iii  inch 
below  the  floor  of  this  opening  before  reaching  the  base  of  the  skull. 


Fig.  294. — Transverse  section  of  mastoid  process  showing  the  cells,  tlie  iipiier  largest  one 
being  the  mastoid  antrum.  Note  its  relation  to  the  external  auditory  meatus.  The 
upper  and  outer  sharp  point  of  the  reflected  bone  flap  is  a  portion  of  the  meatal 
spine. 

The  supra-meatal  spine  placed  at  the  upper  margin  of  the  bony  meatus 
is  found  in  82  per  cent  of  3^oung  and  87  per  cent  of  adult  sul^jects.     This 


Pig.  395.— Reflected  portion  of  mastoid  cells  removed,  showing  mastoid  antrum  above 
communicating  with  attic,  seen  through  the  window  caused  by  separation  of  the 
halves  of  bone.  Note  the  thinness  of  the  bony  roof  of  the  attic,  the  Fallopian  canal, 
external  auditory  walls,  and  the  relations  of  the  important  intracranial  parts  to 
those  without. 

spine  is  an  important  guide  to  the  upper  margin  of  the  bony  meatus  (Fig. 
294),  to  the  mastoid  antrum,  and  to  the  lower  limits  of  the  middle  cerebral 


264 


OPERATIVE  SURGERY. 


Fig,  296. — A  vertical  section  of  mas- 
toid process  made  at  right  angles 
with  the  auditory  canal.  *.  The 
mastoid  antrum,  a.  The  squa- 
mous bone.  i.  The  zygoma,  c. 
The  posterior  border  of  the  ex- 
ternal auditory  meatus,  e,  A 
vein.    /.  The  sigmoid  fossa. 


fossa.  The  upper  limit  of  the  bony  meatus  corresponds  to  the  spine  (Fig. 
294) ;  the  lower  limit  of  the  middle  fossa  is  a  trifle  more  tlian  a  quarter  of 
an  inch  above  it ;  the  mastoid  antrum  is  located  half  an  inch  posteriorly  and 

about  two  fifths  of  an  inch  below  the  sur- 
face of  the  bone  at  that  point  (Fig.  294). 
If  the  fingers  be  thrust  into  the  external 
meatus  and  pressed  upward  and  back- 
ward, the  supra-meatal  spine  can  usually 
be  felt  (Fig.  295).  The  mastoid  cells  vary 
in  size  and  shape  in  difEerent  subjects,  and 
are  arranged  in  a  radiating  manner  with 
the  mastoid  antrum  (Fig.  296).  From  a 
surgical  point  of  view,  the  sigmoid  fossa 
(Fig.  296),  the  dura,  and  brain  of  the 
middle  cerebral  (Fig.  296)  and  the  cere- 
bellar fossae,  and  the  facial  nerves  are  of 
special  significance  on  account  of  their 
liability  to  injury  during  operative  prac- 
tice, and  in  this  condition  it  is  wise  to  note 
at  the  -outset  that  the  common  variations 
of  their  relations  to  the  mastoid  antrum 
and  the  varying  thickness  of  its  bony  par- 
titions require  for  their  protection  an  ex- 
ercise of  the  greatest  caution  in  all  in- 
stances (Fig.  295).  "Operating  in  each  as  though  the  most  dangerous 
exceptions  were  present,  at  least  until  the  contrary  is  proven "  (Hart- 
mann). 

The  Operation. — Shave  and  cleanse  the  external  surface  much  beyond 
the  seat  of  operation,  also  cleanse  and  tampon  with  antiseptic  gauze  the 
external  ear;  wrap  the  head  in  a  towel  saturated  with  an  antiseptic  solu- 
tion ;  pull  the  auricle  forward  and  make  a  curved  incision  down  to  the  bone, 
just  behind  the  auricle,  from  its  upper  border  to  the  tip  of  the  mastoid 
process;  push  aside  the  periosteum  with  an  elevator  (Fig.  293,  c),  ex- 
posing the  entire  bony  surface;  carefully  examine  it  to  disclose  a  carious 
point  or  fistulous  opening,  which,  when  noted,  is  enlarged  by  means  of 
gouges  and  (Fig.  293,  i,  j,  Jc,  I)  mallet  and  the  diseased  bone  is  care- 
fully removed  with  small  sharp  spoons  (Fig.  293,  1i)  aiming  to  reach 
the  antrum.  If  no  external  disease  is  manifest,  open  the  antrum  directly 
with  a  chisel,  a  small  trephine  (Fig.  293,  i,  d,  q),  or  a  small  gimlet 
(Treves),  removing  in  advance  the  overlying  bone  in  the  last  instance,  and, 
in  all,  remove  with  a  sharp  spoon,  in  a  line  parallel  with  the  external  audi- 
tory meatus,  the  contents  and  diseased  cellular  structure  contiguous  to  the 
antrum,  forming  a  cone-shaped  cavity  extending  inward  and  slightly  upward, 
not  more  than  three  quarters  of  an  inch  wide  in  adult  cases,  and  communi- 
cating with  the  attic.  Examine  and  remove  from  the  middle  and  lower 
parts  of  the  process  any  diseased  tissue  in  a  similar  manner ;  irrigate  the 
entire  field  with  an  antiseptic  solution,  passing  it  in  through  the  external 


OF'ERATIONS  ON  TUB  NERVOUS  SYSTEM.  265 

meatus,  if  the  condition  of  tlie  tympanic  membrane  will  permit.  A  percep- 
tion of  diminished  resistance,  and  the  appearance  of  pus  on  the  withdrawal 
of  the  instrument,  indicate  the  attainment  of  the  object.  The  cavity  is  then 
drained  and  dressed  with  iodoform  gauze,  supplemented  with  dry  antiseptic 
gauze  and  bandages.  The  dressing  should  be  changed  often,  that  the  wound 
may  be  properly  cleansed. 

The  Precautions. — If  the  incision  of  the  soft  parts  be  carried  too  far 
upward,  the  posterior  auricular  artery  will  be  severed.  If  the  penetration 
of  the  bone  be  not  made  parallel  with  the  long  axis  of  the  auditory  canal, 
either  the  lateral  sinus,  the  external  ear,  or  the  cranial  cavity  may  be 
entered  with  the  instrument.  The  depth  of  the  penetration  and  the  pene- 
trating force  employed  must  be  carefully  estimated,  otherwise  the  cranial 
cavity  will  be  entered  and  infective  meningitis  will  follow.  The  use  of  the 
trephine  devised  for  this  purpose  should  be  limited  to  adults,  owing  to  the 
small  size  of  the  petrous  bone  in  infants  and  children.  Gouges  and  drills 
are  inferior  to  the  gimlet  for  this  purpose,  as  the  latter  may  be  used  slowly 
and  deliberately  while  the  force  necessary  to  drive  the  former  is  estimated 
with  some  difficulty.  If  the  index  finger  be  placed  along  the  side  of  the 
instrument,  or  it  be  grasped  firmly  with  the  disengaged  hand,  the  advance 
of  the  instrument  will  be  properly  controlled.  The  great  desiderata  are  to 
remove  all  of  the  dead  bone,  and  to  thoroughly  cleanse  and  drain  the  wound, 
especially  through  the  external  meatus.  A  strong  light,  preferably  electric, 
should  be  at  hand  during  the  operation.  The  frequent  introduction  of  a 
silver  probe  (Fig.  293,  n)  to  note  the  extent,  direction,  and  compactness  of 
the  limitations  of  the  field  of  operation  should  be  made  during  the  pro- 
cedure. The  layer  of  bone  intervening  between  the  sigmoid  sinus  and  the 
brain  fossa  has  a  blue  look  as  one  approaches  these  cavities,  acting  as  a  signal 
to  arrest  incautious  manipulations.  Painstaking  effort  should  be  exercised 
in  the  removal  of  all  cancellous  tissue,  since  it  may  harbor  infecting  prod- 
ucts and  cause  delay  to  the  recovery.  The  cavity  of  the  external  ear  should 
be  cleansed  and  tamponed  with  gauze  at  each  dressing  of  the  wound,  to 
maintain  proper  cleanliness. 

The  Results. — The  results  are  favorable  if  the  operation  be  done  with 
sufficient  promptness  to  anticipate  the  development  of  the  important  sequels. 
The  operation  itself,  when  cautiously  performed,  is  devoid  of  danger. 

Trephining'  the  Frontal  Sinus. — Trephining  the  frontal  sinus  is  practiced 
for  the  removal  of  foreign  bodies,  necrosed  bone,  etc.,  from  this  cavity.  The 
frontal  sinuses  are  absent  in  the  infant,  rudimentary  in  children,  and  have 
no  surgical  significance  until  after  puberty.  They  differ  much  in  size 
and  extent  in  adults,  and  sometimes  communicate  with  each  other  at  the 
median  line. 

The  Operation. — Cleanse  and  shave  the  surface;  make  a  vertical  incision 
down  to  the  bone,  an  inch  and  a  half  in  length,  from  the  root  of  the  nose 
upward  or  one  transversely  outward  so  that  the  eyebrow  will  hide  the  cicatrix 
(Fig.  308) ;  push  aside  the  periosteum  at  the  point  of  attack ;  open  the  sinus 
with  a  small  trephine  or  sharp  gouge  applied  to  the  anterior  wall ;  cleanse 
the  cavity  with  Thiersch's  fiuid,  remove  foreign  bodies,  diseased  products, 


266  OPERATIVE  SURGERY. 

etc.  If  the  infundibulum  be  closed  or  constricted,  open  it  with  a  bougie. 
Drainage  can  be  made  through  this  canal  into  the  nose  or  through  the  ex- 
ternal wound,  and  perhaps  through  both,  according  to  circumstances.  The 
external  wound  is  treated  in  the  usual  way. 

The  Precautions. — Strong  antiseptic  fluids  should  not  be  employed  here, 
neither  should  the  unrestrained  escape  of  inflammatory  products  be  permit- 
ted, on  account  of  the  proximity  of  the  eyes. 

Gunshot  Wounds  of  the  Cranium. — Much  change  has  taken  place  in  the 
treatment  of  this  form  of  injury  since  the  advent  of  antiseptic  surgery 
and  the  localization  of  brain  centers.  The  consecutive  steps  of  treatment 
divide  themselves  quite-  naturally  into,  1,  the  aseptic  technique ;  2,  the  ar- 
rest of  haemorrhage ;  3,  the  enlargement  of  the  opening  and  the  eleva- 
tion of  depressed  fragments  of  bone ;  4,  the  removal  of  foreign  bodies  from 
the  wound ;  5,  the  establishment  of  good  drainage ;  6,  the  control  of  inflam- 
mation. 

The  antiseptic  technique  should  be  rigid  throughout  in  all  respects  and 
in  each  detail.  The  scalp  is  shaven,  and  thoroughly  scrubbed  and  cleansed, 
and  the  face,  neck,  ears,  and  auditory  meatus  made  thoroughly  clean,  and 
the  latter  plugged  with  iodoform  gauze.  The  surgeon  and  the  entire  outfit 
are  antiseptically  prepared. 

Hemorrhage  from  the  scalp,  skull,  and  membranes  of  the  brain  are  con- 
trolled as  already  indicated  (pages  236  and  241).  Hemorrhage  from  a  sinus, 
if  accessible,  can  be  arrested  promptly  by  an  antiseptic  tampon  and  thereafter 
the  wound  in  the  sinus  can  be  closed  by  sewing  or  tying  the  opening,  or  by 
continued  tamponing,  as  the  character  of  the  injury  suggests.  Haemorrhage 
from  the  brain  substance  will  likely  have  stopped  before  the  patient  is  seen 
by  the  surgeon.  Haemorrhage  from  the  wound  track  in  the  brain  is  diffi- 
cult, indeed,  to  arrest,  especially  if  it  be  severe.  In  fact,  ligature  of  the 
carotid  of  the  same  side  is  advised  by  some  in  obstinate  cases.  The  careful 
introduction  along  the  track  of  the  wound  to  the  bottom  by  means  of  a 
probe  of  a  long,  thin,  infolded  strip  of  iodoform  gauze  serves  not  only  to 
arrest  the  hemorrhage  in  the  great  majority  of  cases,  but  also  acts  as  a 
drainage  agent  at  the  same  time,  which  is  a  matter  of  great  importance, 
especially  if  the  wound  requires  tamponing  before  being  cleansed.  However, 
as  soon  as  the  patient's  condition  permits,  steps  should  be  taken  to  measure 
the  surgical  aspects  of  the  case. 

The  Operation. — Chloroform  anaesthesia  is  advised  if  the  patient  be  not 
already  unconscious  or  at  least  insensible  to  manipulative  procedures.  Place 
the  patient  in  a  good  light ;  make  a  liberal-sized,  oval  scalp  flap,  leaving 
the  pericranium  in  place ;  with  the  rongeur  increase  the  size  of  the  cranial 
opening  sufficiently  to  permit  the  arrest  of  the  bleeding  points  of  the 
bone  and  membranes  of  the  brain ;  also,  to  permit  of  a  suitable  exam- 
ination of  the  extent  of  the  injury.  All  depressed  and  loose  fragments  of 
bone  and  foreign  bodies  that  appear  on  the  surface  of  the  brain  and  at 
the  wound  are  removed,  except  when  the  depressed  bone  can  be  properly 
restored. 

The  foreign  hodies  found  within  the  brain  are  the  bullets,  fragments  of 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


267 


bone,  and  perhaps  hair  and  textile  fabrics.  The  bullet  must  he  located  before 
it  is  removed.  Probes  and  the  X-rays  are  employed  for  this  purpose.  The 
probe  should  be  light,  about  a  quarter  of  an  inch  in  diameter  at  the  advanc- 
ing end,  and  when  used  carried  along  the  track  of  the  ball  with  a  degree 
of  gentleness  and  care  that  will  lead  to  a  prompt  appreciation  of  a  change 


Fig.  297.— Fluhrer's  probe. 

in  the  course  or  the  presence  of  increased  opposition  to  the  passage.  Ruth 
has  determined  that  a  probe  a  quarter  of  an  inch  in  diameter  is  caused  to 
penetrate  normal  brain  tissue  by  a  pressure  equaling  two  and  a  half  to  three 
ounces.  Of  course  a  smaller  end  lessens  proportionally  the  amount  of  pres- 
sure required  for  penetration.  The  probe  devised  by  Fluhrer,  composed  of 
aluminium  (Fig.  297),  and  the  one  devised  by  Girdner,  known  as  the  tele- 
phone probe,  are  as  yet  by  far  the  best  for  the  purpose.  Fluhrer's  probe  is 
so  light  and  bkmt  that  its  passage  along  the  wound  can  do  no  harm,  and, 
too,  it  can  be  manipulated  with  a  delicate,  unweighted  touch.     Girdner's 


Fig.  398. — Girdner's  electric  probe. 

telephone  probe  is  already  so  well  known  as  not  to  require  a  detailed  de- 
scription (Fig.  298).  The  author  is  indebted  to  Dr.  Girdner  for  the  fol- 
lowing brief  statement  of  the  use  of  his  probe:  "  Place  the  metal  bulb  (a) 
in  the  patient's  buccal  cavity  between  the  teeth  and  cheek.  Hold  the 
receiver  (6)  to  the  (your)  left  ear  with  the  left  hand.     Take  the  probe 


268 


OPERATIVE  SURGERY. 


handle  (c)  in  the  right  hand  and  explore  the  wound  for  the  bullet  or  other 
metallic  substance.  No  sound  will  be  heard  in  the  receiver  when  the  probe 
(d)  touches  soft  tissues  or  bone,  but  the  slightest  contact  of  the  probe  with 
a  metallic  body  produces  a  sharp  clicking,  grating,  or  rustling  sound  in  the 

receiver.      No  hat- 

_o 

MM 


Fig.  299.— Bullet  forceps, 


tery  of  any  kind  is 
tised.  The  current 
which  operates  the 
instrument  is  de- 
rived from  the  body 
of  the  patient;  in 
other  words,  each  patient  supplies  from  his  own  body  the  current  necessary  to 
locate  the  missile  it  contains."  Not  only  will  this  instrument  indicate  the  site 
of  the  bullet,  but  it  will  locate  also  the  lead  fragments  that  are  shed  by  it 
along  its  passage  through  bone,  a  fact  that  may  mislead  the  surgeon,  unless 
the  probe  with  the  insulated  stem  be  used.  This  instrument  finds  its  most 
significant  use  in  locating  missiles  in  the  brain,  since  it  responds  to  the  most 
delicate  touch  of  a  metal  substance.  If  the  bullet  he  located,  the  question  of 
removal  through  the  point  of  entrance,  through  a  counter-opening,  or  leaving 
it  alone  must  be  considered.    If  it  be  in  the  opposite  hemisphere  of  the  brain, 


Fig.  300. — Author's  method  of  locating  site  of  counter-opening. 

and  can  be  reached  with  forceps  (Fig.  399),  carefully  introduced,  grasped 
and  withdrawn  without  force,  well  and  good.  However,  it  is  better  practice, 
in  my  judgment,  to  make  a  counter-opening  promptly,  remove  the  missile 
and  establish  good  drainage,  than  to  encounter  the  dangers  of  prolonged  and 
uncertain  effort  that  too  often  attend  attempts  of  direct  approach  and  re- 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


269 


moval.  //  the  missile  have  gone  th.rougJi,  the  head,  good  drainage  can  then 
be  easily  established.  This  is  accomplished  by  passing  the  Fluhrer  probe 
carefully  along  the  track  of  the  wound,  and  out  through  the  opposite  open- 
ing, attaching  a  thread  to  the  end,  withdrawing  the  probe,  and  leaving  the 
thread  in  the  track  of  the  wound,  by  aid  of  which  a  No.  9  or  10  French 
fenestrated  catheter,  thoroughly  disinfected,  is  drawn  into  the  wound  and 
left  for  drainage  purposes.  //  a  bullet  can  he  approached  safely  through  a 
counter-opening,  the  proper  site  for  this  opening  can  be  found  by  pushing 
a  long  probe  past  the  bullet  through  the  brain  to  the  skull  (Fig.  300,  a,  h). 
Now,  if  a  string  be  attached  to  the  outer  end  of  the  probe,  and  be  carried 
across  the  head  at  various  points  (Fig.  300  c,c,c,c),  while  placed  each  time  in 
a  direct  line  with  the  protruding  portion  of  the  probe,  it  is  manifest  that  the 
point  of  crossing  of  these  lines  will  correspond  to  the  point  of  impingement 
on  the  skull  of  the  intracranial  end  of  the  probe,  at  which  point  the  opening 
should  be  made  (Fig.  301,  d).  The  end  of  the  probe  is  then  carried  through 
the  opening,  and  the  bullet  is  sought  for  by  a  grooved  director  passed  suc- 
cessively through  the  tissues  on  all  sides  of  the  probe.  When  found  the 
bullet  is  removed  by  forceps  passed  along  the  grooved  director.  After  this 
the  fenestrated  catheter  is  drawn  into  position  the  same  as  before.  This 
plan  which  was  devised 
in  1887  by  the  author 
and  employed  at  once 
with  success  on  a  case 
in  Bellevue  Hospital  is 
eminently  practical  and 
can  be  promptly  util- 
ized, requiring  only  a 
long  probe  and  a  string 
for  the  purpose.  If  the 
bullet  strikes  the  oppo- 
site side  of  the  skull,  the 
probe  is  introduced  to 
the  point  of  impinge- 
ment, and  the  seat  for 
the  counter-opening  is 
indicated  and  made  as  in 
the  preceding  instance. 
However,  the  bullet  in 

this  instance  is  likely  to  be  at  a  distance  of  an  inch  or  so  from  the  point  of 
impingement,  in  the  direction  indicated  by  the  angle  of  incidence.  In  such 
cases  the  counter-opening  should  be  not  less  than  an  inch  and  a  half  in 
diameter,  to  admit  of  easy  exploration  for  the  ball.  The  course  of  the  re- 
flected ball  through  the  brain  is  sometimes  apparent ;  again,  it  may  be  neces- 
sary to  locate  it  with  the  aid  of  a  sharp  needle  passed  into  the  brain  in  the 
direction  of  the  line  of  incidence.  In  efforts  of  this  kind  the  needle  probe 
of  the  Girdner  apparatus  is  of  great  value,  as  by  its  use  the  bullet  can  be 
located  with  certainty  and  with  a  minimum  injury  of  the  brain.     If  a  deep- 


FiG.  301.- 


-Site  of  counter-opoumg  (d)  located  by  author's 
method. 


2Y0  OPERATIVE   SURGERY. 

seated  bullet  be  touched  with  a  probe,  and  the  direction  of  the  wound  be 
such  that  the  establishment  of  a  counter-opening  in  its  course  is  impossible 
or  unwise,  then  perhaps  a  large  opening  can  be  made  through  the  skull  at  a 
point  nearest  to  the  ball.  Through  this  opening  the  ball  is  sought  for  and 
located  with  the  needle  probe  of  Girdner,  which  if  left  in  position  in  the  brain 
affords  a  certain  guide  to  the  missile,  which  can  then  be  removed  as  before. 
In  such  instances  as  this  suitable  drainage  for  each  portion  of  the  wound  is 
necessary,  as  a  drainage  agent  can  not  be  carried  through  an  angular  wound 
of  the  brain  for  obvious  reasons.  If  a  bullet  can  not  be  found,  or  if  removal 
be  inadvisable,  a  small  fenestrated  rubber  tube  is  introduced  gently  into  the 
wound  as  far  as  practicable,  fastened  in  position,  and  flushed  gently  with 
warm  Thiersch's  fluid  or  the  warm  saline  solution. 

After-treatment. — After  the  tube  is  fastened  in  position  and  the  wound 
is  carefully  dressed  with  dry  antiseptic  gauze  bound  lightly  in  place,  the 
patient's  head  is  so  arranged,  if  feasible,  that  the  force  of  gravity  will  favor 
the  escape  of  discharges  from  the  wound.  The  controlling  of  inflammation 
requires  that  the  head  and  shoulders  be  raised,  a  cold  water  coil  applied  to  the 
head,  bowels  freely  moved,  and  that  anodynes  be  administered  according  to 
circumstances.  The  wound  should  be  dressed  as  often  as  proper  cleanliness 
requires  for  the  purpose  of  hastening  repair  and  the  prevention  of  septic 
meningitis.  Thiersch's  fluid  and  the  saline  solution  used  warm  are  the  best 
agents  for  flushing  purposes,  as  they  are  unirritating.  After  the  repair  of 
the  wound  is  well  under  way,  horsehair  as  a  drainage  agent  should  be  sub- 
stituted for  the  rubber  tube.  The  interchange  can  be  easily  and  safely 
made  by  pushing  into  the  end  of  the  rubber  tube  for  a  short  distance  a 
small  wisp  of  aseptic  horsehair,  which  is  then  left  in  position  by  the  with- 
drawal of  the  tube.  As  the  wound  heals,  the  increase  in  repair  is  accom- 
modated from  time  to  time  by  the  withdrawal  of  a  proportionate  amount  of 
the  hair. 

The  Precautions. — Avoid  the  cranial  sinuses  in  making  counter-openings, 
and  also  the  basal  ganglia  in  explorations.  If  a  bullet  be  in  the  lateral  ven- 
tricles it  is  dangerous  and  useless  to  attempt  the  removal.  If  a  bullet  be 
near  the  ventricles  it  is  very  liable  indeed  to  be  pushed  into  them  by  efforts 
of  removal.  A  much  spent  bullet  will  not  rebound  at  an  angle  equal  to 
that  of  incidence,  but  will  remain  in  contact  with  the  skull  and  membranes 
at  a  point  near  to  that  of  primary  impingement.  Fragments  of  bone  and 
other  foreign  bodies  lying  in  the  course  of  the  wound  must  be  carefully 
sought  for  and  removed  before  using  the  Fluhrer  probe,  to  avoid  their 
being  carried  still  farther  into  the  brain  by  the  introduction  of  this  agent. 
In  fact,  after  the  removal  of  these  bodies,  the  introduction  along  the 
track  of  the  ball  of  a  small  fenestrated  rubber  tube  and  the  backward 
flushing  incident  to  the  careful  introduction  into  it  of  a  warm  saline  solu- 
tion, may  not  only  cleanse  the  wound  but  check  the  oozing  from  the  brain 
substance. 

The  Results. — The  following  tables,  which  were  a  part  of  a  paper 
read  before  the  New  York  State  Medical  Society  in  1888  by  the  author, 
speak  for  themselves  of  the  wisdom  of  operative  procedure,  although  not 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


271 


with  sufficient  emphasis,  as  these  results   are  not  the   product  of   aseptic 
method  : 


Lobes  of  Brain  Implicated. 


Frontal 

Parietal 

Teinporo-sphenoidal 

Occipital 

Cerebellar 

Frontal  and  parietal 

Frontal  and  temporo-sphenoidal 

Frontal,  temporo-sphenoidal,  and  occipital. . . . 

Parietal  and  occipital 

Temporo-sphenoidal  and  occipital 

Temporo-sphenoidal,  pons,  and  crura  cerebelli 


BALLS    REMOVED   AND   ES- 
CAPED  PRIMARILY. 


Total 85 


No. 


33 
6 

15 
8 
4 
3 
6 
5 
2 
2 
1 


Died. 


17 
1 
3 
3 
4 
1 
3 
3 
1 
1 
1 


38 


Recov- 
ered. 


16 
5 

12 
5 
0 
2 
3 
2 
1 
1 
0 


47 


BALLS   NOT   REMOVED. 


No. 


27 
5 
9 
6 
2 
1 
0 
3 
0 
2 
0 


55 


Died. 


13 
4 
6 
3 
1 
1 
0 
3 
0 
1 
0 


32 


Recov- 
ered. 


14 
1 
3 
3 
1 
0 
0 
0 
0 

1 

0 


23 


Tabulated  Statement  of  the  Cases  in  ivhich  the  Missiles  Escaped 

Primarily. 


No. 


Frontal  lobes 3 

Parietal  lobes \  0 

Temporo-sphenoidal  lobes I  8 

Occipital  lobes !  3 

Cerebellar  lobes j  3 

Frontal  and  parietal  lobes 1  0 

Frontal  and  temporo-sphenoidal  lobes '  6 

Frontal,  temporo-sphenoidal,  and  occipital I  3 

Parietal  and  occipital  lobes I  1 

Temporo-sphenoidafand  occipital  lobes j  1 

Temporo-sphenoidal,  pons,  crura  cerebelli ;  1 


Total 29 


Died. 


14 


Recov- 
ered. 


15 


The  showing  fav^oring  surgical  interference  in  this  series  of  cases  is 
greater  than  that  of  many  others,  notably  those  of  Huhn,  which  only  slight- 
ly favor  removal.  Fowler,  however,  reports  sixty  cases  treated  under  aseptic 
and  antiseptic  methods  with  the  following  results  :  Bullet  removed  in  twenty- 
four  cases,  mortality  sixteen  per  cent ;  not  removed  in  thirty-six  cases,  mor- 
tality fifty-uine  per  cent. 


THE    SPECIAL   OPERATIONS    ON    NERVES. 

It  often  becomes  necessary,  on  account  of  neuralgia,  spasm,  tremor,  vio- 
lence, etc.,  to  operate  on  the  trunk  of  the  nerve  involved  after  other  means 
have  failed  either  by,  1,  nerve-section  or  neurotomy ;  2,  nerve-resection  or 
neurectomy ;  3,  nerve-stretching  or  neurectosy ;  4,  nerve-avulsion,  or  tearing 
away;  5,  nerve-suture  or  neurorrhaphy;  G,  nerve-grafting. 

Nerve-section  and  nerve-resection  differ  in  the  extent  of  the  operative 


272  OPERATIVE  SURGERY. 

procedure.  In  the  former,  the  nerve  is  divided  at  one  point ;  in  the  latter, 
at  two  separate  points,  and  the  intervening  portion  of  the  nerve  is  removed. 
Either  of  these  measures  can  be  practiced  singly  or  in  conjunction  with 
nerve-stretching,  the  latter  always  taking  precedence.  The  portion  of  the 
trunk  of  the  nerve  attacked  either  in  section  or  resection  should,  1,  be 
healthy  at  the  seat  of  operation ;  2,  be  located  at  the  proximal  side  of  the 
seat  of  the  disease  calling  for  the  operation ;  3,  should  command  the  sen- 
sory fibers  of  the  diseased  area,  for  otherwise  the  operation  can  not  be  en- 
tirely successful ;  4,  should  not  include  important  motor  fibers.  Nerve- 
section  is  not  much  employed  now,  as  it  affords  but  temporary  relief,  owing 
to  the  more  or  less  prompt  repair  of  the  divided  nerve.  Nerve-resection 
is  commonly  employed  instead,  and  the  length  of  the  portion  removed  de- 
pends, of  course,  on  the  size  and  length  of  the  nerve  trunk  involved ;  not 
less  than  two  inches  should  be  removed  if  practicable ;  and  even  then  in 
some  instances  the  divided  extremities  are  turned  away  from  each  other, 
or  tissues  are  interposed  between  them  to  fortify  against  the  possibility  of 
a  future  reunion.  Nerve-section  is  done  by  either  the  subcutaneous  or 
open  methods ;  the  latter  is  the  more"  successful  measure  and  less  liable  to 
cause  injury  of  contiguous  structures ;  but  it  invites  the  presence  of  cosmetic 
defects.  While  in  the  great  majority  of  instances  these  operations  assume 
no  special  magnitude,  still  strict  aseptic  measures  should  be  a  part  of  the 
entire  procedure. 

Nerve- stretching. — Nerve-stretching  has  a  greater  range  of  application 
than  has  the  division  of  nerves,  and  its  employment  usually  antedates  the 
use  of  the  severer  operative  measures.  A  failure  of  this  means  of  treat- 
ment is  not  followed  by  a  long  or  grievous  disturbance  of  function,  as  the 
immediate  effects  are  of  comparatively  short  duration.  The  following  facts 
relating  to  this  procedure  are  of  practical  interest :  Nerves  can  be  stretched 
about  one  twentieth  of  their  length ;  nerves  in  central  locations  are  less 
extensile  than  are  those  in  peripheral ;  nerves  near  to  the  spinal  cord  are 
more  extensile  than  are  those  at  a  distance ;  those  of  the  upper  are  more  so 
than  those  of  the  lower  extremities. 

The  traction  is  made  with  the  thumb  and  finger,  the  finger  alone,  or 
with  a  hooked  instrument;  it  is  made  gradually  and  forcibly,  the  force 
employed  corresponding  to  the  size  and  seat  of  the  nerve,  and  is  directed  to 
the  central  and  peripheral  extremities  alternately.  If  a  sense  of  a  limited 
and  sudden  giving  away  happens  traction  should  cease  at  once,  as  rupture 
of  the  entire  nerve  may  quickly  follow.  In  dry  stretching  these  measures 
are  unnecessary.  The  degree  of  traction  exercised  will  be  expressed  in 
connection  with  the  operations  on  the  respective  nerves. 

Nerve-avulsion  consists  in  the  tearing  away  of  a  nerve  from  the  central 
or  peripheral  ends,  aided,  perhaps,  by  division  of  branches  or  trunks. 

Nerve-suture. — There  is  now  no  question  of  the  fact  that  the  ends  of 
divided  nerves  should  be  united  with  each  other,  when  possible,  with  sutures. 
Although  this  course  is  not  followed  by  restoration  of  function  in  all  in- 
stances, still  the  frequent  happy  results  that  follow  the  measure  admonish 
the  surgeon  to  be  prompt  and  urgent  in  the  treatment  of  these  cases. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


273 


Primary  and  secoiulanj  suturing  are  practiced;  the  foniici"  relates  to 
recent,  the  latter  to  old  cases  of  nerve  division.  In  both  instances,  however, 
only  recentl}^  divided  or  freshened  nerve  extremities  are  united  with  each 
other.  In.  primurij  suturing  (Fig.  303),  with  no  loss  of  substance,  the  ex- 
tremities can  be  united  at  once  with  two  fine  catgut  or  silk  sutures  passed 
through  the  ends  of  the  nerves  at  right  angles  to  each  other  (a)  with  a  fine 
needle  and  tied.  The  sutures  should  be  passed  as  near  to  the  periphery  of 
the  nerve  as  is  consistent  with  proper  repair,  even  if  the  sheath  of  the  nerve 
only  be  transfixed  (&).  Any  tension  at  the  line  of  junction  of  the  extremi- 
ties should  be  avoided,  as  it  greatly  prejudices  the  chances  of  cure.  The 
tying  of  the  ends  (c)  is  seldom  practicable,  and  in  no  event  a  suitable  substi- 
tute for  sewing.  Tension  of  a  nerve  is  commonly  the  result  of  a  loss  of  sub- 
stance or  retraction  of  the  nerve,  due  to  injury,  or  is  the  outcome  of  the 
freshening  of  the  divided  ends  for  reparative  purposes.  Tension  or  separa- 
tion of  the  extremities  may  be  lessened,  or  overcome  entirely,  by  stretching 
the  nerve,  by  flexion  of  the  part  containing  it,  and  by  nerve-grafting.  The 
shortening  of  a  limb  by  excision  of  the  bone  to  meet  curtailment  of  the 
nerve  is  such  a  harsh  method  of  action  that  it  should  not  be  contemplated, 
except  under  the  most  urgent  demands.  Variously  arranged  sutures  are  ad- 
vised for  the  union  of  divided  nerves,  but  usually  the  one  just  described  is 
quite  as  good  as  any.  Fig.  302,  d,  e,  f,  shows  another  and  a  serviceable 
method  of  repair. 


b  c  d  e 

Fig.  303. — Primary  suturing  of  nerves. 


In  a  few  instances  and  under  favorable  circumstances,  union  has  taken 
place  in  three  or  four  days,  as  indicated  by  returning  sensation.  However, 
a  like  number  of  weeks  is  the  common  period,  and  in  some  cases  months 
and  even  years  may  elapse  before  the  evidences  of  union  appear,  if  at  all. 

Secondary  suturing  is  applicable  to  cases  of  old  injul\y  of  nerves  in  which 
loss  of  function  and  atrophy  have  supervened.  The  ends  of  the  nerve  are 
usually  widely  separated,  and  are  adherent  to  the  contiguous  tissues.  The 
proximal  end  is  bulbous,  the  distal  atrophied,  and  both  are  imbedded  in 
cicatricial  tissue.  The  operation  is  aseptic  in  every  detail.  The  Esmarch 
bandage  is  sometimes  emploj'cd.     The  nerve  ends  are  exposed,  the  nerves 


2Y4 


OPERATIVE  SURGERY. 


stretched,  and  cicatricial  tissue  removed.  Thin  laj^ers  are  sliced  off  from 
the  end  of  the  bulbous  extremity  until  healthy  nerve  tissue  is  reached.  If 
any  part  of  the  bulbous  extremity  remain,  it  is  utilized  as  a  firm  basis  for 


ah  c 

Fig.  303. — Gleiss's  method  of  secondary  suture. 


sewing  purposes.  The  distal  end  is  trimmed  but  little,  scarcely  a  quarter  of 
an  inch,  for,  says  Bowlby,  "  It  is  seldom  necessary  to  remove  as  much  as  a 
quarter  of  an  inch,  and,  however  unhealthy  the  section  may  look,  no  good  is 
ever  to  be  gained  by  a  further  sacrifice."  From  three  to  four  sutures  of 
fine  catgut,  silk,  or  kangaroo  tendon,  are  passed  through  the  nerve  at  about 
a  quarter  of  an  inch  from  the  extremities  and  tied.  A  cambric  needle  or 
any  small  needle  with  non-cutting  borders  should  be  employed  to  carry  the 
sutures.  Owing  to  the  cicatrix  it  may  expedite  matters  if  the  nerve  be  iso- 
lated outside  of  the  cicatricial  tissue,  and  then  followed  to  the  seat  of  injury, 
rather  than  that  it  be  directly  approached  at  that  point.  Gleiss  advocates 
the  following  methods  of  union  in  these  instances,  and  reports  ten  complete 
cures  in  eleven  cases — grafting  is  practiced  in  one  instance  {a) ;  linear  di- 
vision (&),  followed  by  approximation  and  sewing  in  the  other  (c)  (Fig.  303). 
The  wound  is  closed  without  drainage  and  the  tissues  are  relaxed  by  posture, 
if  possible,  and  the  limb  firmly  fixed  by  an  immovable  splint  until  the  wound 
is  healed.  After  this,  massage  and  galvanism  should  be  employed  to  restore 
the  tone  of  the  parts. 

The  Results. — The  results  are  flatteringly  exhibited  in  the  following  table 
(Bowlby)  : 


Total. 

80 
73 


Primary  suture.  .  . 
Secondary  suture. 


Suc- 
cessful. 

Im- 
proved. 

Fail- 
ure. 

32 
32 

34 
26 

14 
15 

Neuroplasty  is  utilized  to  fill  in  the  gap  between  the  ends  of  nerves 
which  nerve-stretching,  position  of  the  limb,  etc.,  have  failed  to  accom- 
plish. Single  (a,  a)  and  double  {h,  i)  flaps  of  the  extremities  of  the  nerves 
are  made  as  occasion  demands,  and  are  united  with  each  other  or  with  the 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


2Y5 


nerve  extremity,  as  indicated  in  the  illustration  (Fig.  304).  In  neuroplasty 
for  cure  of  old  injuries  the  method  of  Duncan  commends  itself  for  trial 
(Fig.  305).  The  connection  of  the  ex- 
tremities by  one  or  several  strands  of 
fine  catgut  by  sewing   (Fig.  306),  and 


ah  ah 

Fig.  304. — Neuroplasty.     Secondary  suturing  of  nerves. 

the  grafting  of  one  nerve  to  another  (Fig.  307),  as  in  cases  where  impaired 
nerves  run  parallel  with  each  other — i.  e.,  the  arm,  forearm,  etc. — and  the 
ingrafting  the  gap  with  recent  human  or  animal  nerve  tissue  by  means  of 
sutures,  aided  with  bone   ferule,  are  sometimes  followed  by  results  which 

offer  encouragement  for  continued  effort  in  this 

direction. 


b'    >B         M 


A': 


d 


n 


Fig.  305. 

Duncan's    method    of 

neuroplasty. 


Fig.  306. 

Repair  of  nerves 
by  catgut. 


Fig.  307. — Grafting  of  adjacent  nerves 
for  a  nerve  defect.  C.  Central  or- 
gan.    P.  Peripheral. 


276 


OPERATIVE  SURGERY. 


OPEEATIONS    OJST    SPECIAL   NERVES. 

In  the  consideration  of  special  nerves  only  such  points  as  are  distinctly 
applicable  to  each  of  them  will  be  stated,  as  the  general  technique  of  opera- 
tions on  nerves  has  been  considered  sufficiently  already. 

FIRST    DIVISIOlSr    OP   THE   TRIFACIAL   NERVE. 

The  Supra-orhital  Nerve. — The  supra-orbital  nerve  can  be  divided,  re- 
sected, and  stretched  at  its  exit  from  the  supra-orbital  foramen  or  notch 
located  at  the  junction  of  the  inner  and  middle  thirds  of  the  supra-orbital 
arch.     If  a  notch  be  present,  it  can  be  readily  felt  with  the  finger.    At  this 


SUPRA- 
TROCHLEAR N  j 

SUPRAORBITAL 
A.  AND  N.       f 

ORBICULARIS 
PALP.  M.      I 


ORBICULARIS 
PALPIM. 
LEVATOR    LABI  I 
SUPERIOR!  5. 

niFRAORBITAL  N: 


Pig.  308. — Supra-orbital  and  infra-orbital  nerves  and  frontal  sinus. 


situation  the  nerve  is  covered  by  integument,  fascia,  and  the  combined  fibers 
of  the  orbicularis  palpebrarum,  occipito-frontalis,  and  corrugator  supercilii 
muscles.     It  is  accompanied  by  vessels  of  the  same  name  as  itself.     The 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  277 

nerve  often  divides  into  two  branches  before  reaching  the  seat  of  operation. 
It  may  be  divided  by  the  subcutaneous  or  by  the  opan  method.  If  by  the 
former,  steady  the  eyebrow  and  locate  the  notch  with  the  left  hand ;  then  pass 
the  point  of  a  narrow  bistoury  beneath  the  integument  from  within  outward, 
turn  the  edge,  and  cut  strongly  across  the  notch  toward  the  upper  boundary. 
A  firm  compress  should  be  applied  to  the  wound  at  once  to  control  the 
bleeding  from  the  supra-orbital  vessels.  The  nerve  can  be  divided,  resected, 
or  stretched  through  either  of  the  following  cutaneous  incisions: 

The  First  Operation. — Steady  the  eyebrow  with  the  left  hand;  with  the 
right  draw  the  eyelid  downward  and  hold  it  with  the  thumb  of  the  left. 
Make  a  horizontal  incision  about  an  inch  in  length  along  the  superior  mar- 
gin (Fig.  308,  c)  of  the  orbit — the  center  corresponding  to  the  notch — 
through  the  tissues  down  to  the  nerve ;  expose  and  treat  the  nerve,  avoiding 
the  vessels.  A  vertical  incision  (Fig.  311,  a-)  at  the  notch  would  be  the  bet- 
ter one,  were  it  not  that  a  freer  division  of  the  muscles  is  made  and  a  greater 
danger  of  scarring  incurred. 

The  Second  Operation. — Elevate  the  brow  with  the  left  hand ;  with  the 
right  draw  down  the  lid  and  hold  it  as  before.  Make  an  incision  between 
the  brow  and  the  lid  one  inch  in  length  through  the  tissues  down  to  the  site 
of  the  nerve  (Fig.  312,  a).  Push  aside  the  connective  tissue  and  isolate  the 
nerve.  In  stretching,  seize  the  nerve  with  an  aneurism  needle  curved  at  the 
side.  Since  in  the  dead  subject  this  nerve  parts  under  a  six-pound  strain, 
much  caution  must  be  exercised  in  stretching  it  in  the  living,  otherwise  it 
will  rupture.  The  nerve  can  be  pulled  out  from  the  roof  of  the  orbit  with 
a  small,  blunt  hook,  and  treated  before  it  enters  the  foramen  or  notch. 

The  Supratrochlear  Nsrve. — The  supratrochlear  nerve  is  stretched  in 
certain  cases  of  glaucoma  and  ciliary  neuralgia.  The  nerve  escapes  from  the 
orbit  above  the  pulley  of  the  superior  oblique  muscle  (Fig.  308,  c).  A  line 
drawn  from  the  angle  of  the  mouth  through  the  inner  canthus  to  the  margin 
of  the  orbit  indicates  the  course  of  the  nerve  at  this  situation. 

The  Operation. — Make  an  incision  with  the  convexity  downward  at  the 
upper  part  of  the  inner  angle  of  the  orbit  (Fig.  308,  e)  directly  below  the 
eyebrow;  draw  apart  the  borders  of  the  wound;  locate  the  pulley  of  the 
superior  oblique,  and  find  the  nerve  just  above  it;  raise  the  nerve  with  a 
hook  and  stretch  it  cautiously. 

SECOND    DIVISION    OF    THE   TRIFACIAL. 

The  Infra-orhital  Nerves. — The  infra-orbital  nerves  are  the  terminal 
branches  of  the  second  or  supra-maxillary  division  of  the  fifth  pair.  They 
are  present  at  the  infra-orbital  foramen,  which  is  located  about  four  lines 
below  the  lower  edge  of  the  orbit,  and  nearly  on  a  line  extending  from  the 
bicuspid  teeth  to  the  supra-orbital  foramen. 

The  infra-orbital  nerves  (nasal,  palpebral,  etc..  Fig.  309)  can  be  divided 
through  the  mouth  by  first  recognizing  the  location  of  the  infra-orbital  fora- 
men and  placing  the  finger  upon  it.  Then  turn  up  the  cheek  and  make  a 
narrow  incision,  beginning  at  the  fold  of  the  cheek  and  maxilla,  and  carry  it 
upward  in  the  line  of  the  foramen  until  within  a  short  distance  of  it,  when 
20 


278 


OPERATIVE  SURGERY. 


the  nerves  are  divided  with  a  sharp-pointed  scissors  as  they  appear  at  the 
opening.  The  nerves  can  be  exposed  through  an  incision  made  as  follows: 
The  Operation. — Make  an  incision  with  the  convexity  downward  at  the 
lower  margin  of  the  orbit,  with  the  center  at  the  infra-orbital  foramen  ( Fig. 
308,  a).  Divide  the  orbicularis  and  levator  labii  superioris;  pull  asunder 
the  margins  of  the  wound  and  expose  the  nerves,  avoiding  the  infra-orbital 
vessels.  The  nerves  can  now  be  treated  as  indicated.  It  is  wise  to  remem- 
ber, however,  that  these  nerves  arise  from  the  superior  maxillary  in  the 
infra-orbital  canal  but  a  short  distance  behind  the  foramen.  The  division 
at  the  foramen  can  do  no  good  if  the  lesion  be  behind  the  point  of  section. 


AURICULO-TEMPORAL 
NERVE 


Fig.  309. — Divisions  of  the  trifacial  nerve. 


Even  the  sensation  of  the  teeth  supplied  by  the  anterior  dental  branch  of 
the  superior  maxillary  is  not  disturbed  by  it.  This  nerve  can  be  divided 
subcutaneously  at  its  exit  from  the  foramen  by  a  short,  thin  knife  directed 
against  the  posterior  wall  of  the  opening.  The  division  of  the  infra-orbital 
vessels  will  cause  quite  severe  haamorrhage. 

The  Superior  Maxillary  Nerve  and  MecTceVs  Ganglion. — The  superior 
maxillary  nerve  is  one  of  the  divisions  of  the  great  sensory  nerve  of  the 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  279 

face.  It  has  three  portions  of  much  surgical  interest:  1,  the  infra-orbital 
portion;  2,  the  spheno-maxillar}^  portion,  with  Meckel's  ganglion;  3,  the 
intracranial  portion.  The  first  or  infra-orbital  portion  lies  in  a  canal  or 
groove  of  the  floor  of  the  orbit,  which  extends  from  the  spheno-maxillary 
fossa  to  the  infra-orbital  foramen.  The  walls  of  this  passage  are  exceed- 
ingly thin,  except  at  the  terminal  foramen.  The  dental  branches  arising 
from  the  nerve  as  it  passes  along  the  floor  of  the  orbit  are  the  anterior,  mid- 
dle, and  posterior  (Fig.  309),  the  first  and  last  of  which,  respectively,  come 
from  the  extremes  of  this  portion  of  the  nerve.  The  infra-orbital  portion  of 
the  nerve  can  be  exposed  in  the  infra-orbital  canal  by  one  of  two  or  more 
procedures.  However,  the  presence  in  the  posterior  wall  of  the  antrum  of  the 
posterior  dental  branches  demands  that  great  care  be  taken,  or  they  will  re- 
main undisturbed.  The  nerve  can  he  divided  at  the  floor  of  the  orbit  by 
passing  a  sharp-pointed  tenotome  backward  on  the  floor  in  the  course  of  the 
nerve  for  an  inch  or  so,  then  turning  the  edge  downward  and  cutting 
through  the  bony  walls  of  the  canal  at  a  right  angle  with  the  antero-poste- 
rior  axis  of  the  orbit.  The  infra-orbital  foramen  is  then  exposed,  the  nerve 
grasped  and  pulled  out,  leaving  behind  the  posterior,  and  perhaps  middle 
dental  branches,  llie  nerve  can  he  stretched  at  any  situation  in  its  course, 
after  elevation  from  the  canal,  by  means  of  a  blunt  hook  passed  along  the 
floor  of  the  orbit  through  a  narrow  incision  of  the  soft  parts,  made  at  the 
lower  margin  of  the  orbit  with  a  sharp-pointed  bistoury.  The  nerve  is 
hooked  up  and  stretched,  then  resected  if  need  be.  The  breaking  strain 
in  the  dead  subject  is  twelve  pounds.  The  division  and  removal  of  the  nerve 
at  the  anterior  horder  of  the  spheno-maxUlary  fissiire  is  a  brilliant  procedure, 
although  not  commonly  practiced  on  account  of  the  guarded  manipulation 
essential  to  success. 

A7i  Operation  for  Division  and  Removal. — Through  either  a  vertical  in- 
cision an  inch  in  length  made  from  the  lower  margin  of  the  orbit,  or  a  curved 
one  of  the  same  length  made  at  this  margin,  expose  the  infra-orbital  nerve  on 
the  face.  Now,  through  a  narrow  incision  made  below  the  inferior  tarsal 
ligament  at  the  outer  angle  of  the  orbit,  introduce  a  curved,  blunt,  narrow- 
bladed  tenotome  and  pass  it  along,  with  the  edge  downward,  in  the  direc- 
tion of  the  apex  of  the  orbit,  until  it  reaches  the  posterior  part  of  the 
spheno-maxillary  flssure ;  *  then  press  the  edge  downward  and  draw  the 
blade  forward  and  outward  along  the  anterior  border  of  the  fissure  to  near 
its  outer  extremity,  thus  dividing  the  submaxillary  nerve  at  the  entrance 
to  the  groove.  The  nerve  is  then  carefully  pulled  away  by  gradual  trac- 
tion addressed  to  the  infra-orbital  branch.  The  coincident  division  of  the 
infra-orbital  artery  causes  considerable  haemorrhage,  which  is  often  fol- 
lowed by  a  transient  exophthalmos.  The  ultimate  results  of  this  method 
are  better  by  far  than  are  those  of  the  other  infra-orbital  methods,  as  it 
assuredly  severs  the  dental  branches  from  any  central  connection.  How- 
ever, the  depth  of  the  wound,  the  importance  of  the  structures  of  the  orbit, 
the  delicacy  of  the  operative  technique,  and  the  liability  of  severe  hsemor- 

*  See  Articulated  Bones  of  Orbit. 


280  OPERATIVE  SURGERY. 

rhage  and  of  missing  the  nerve  entirely,  make  this  plan  of  action  so  risky 
and  uncertain  that  the  following  mode  of  procedure  for  division  and  re- 
moval of  the  nerve  is  recommended : 

The  Operation. — Make  an  oblique  or  Y-shaped  incision  (Fig.  308,  /)  be- 
low the  lower  border  of  the  orbit  down  to  the  bone,  so  as  to  expose  the  nerve ; 
isolate  and  tie  with  a  strong  ligature  the  terminal  branches  of  the  nerve  as 
they  emerge  from  the  infra-orbital  foramen ;  cut  away  with  a  chisel  or  ron- 
geur the  orbital  border  of  the  foramen  (Fig.  309) ;  separate  the  periosteum 
from  the  floor  of  the  orbit  back  to  the  spheno-maxillary  fissure  with  a  thin 
periosteotome ;  raise  upward  the  periosteum  and  the  contents  of  the  orbit 
with  a  thin  right-angled  retractor ;  raise  the  nerve  upward  into  the  orbit  as 
it  is  liberated  from  its  channel  with  scissors,  back  to  the  fissure;  carry  be- 
neath the  nerve  from  before  backward  as  far  as  possible  a  hook  with  a  right- 
angled  upward  curve,  thus  freeing  the  nerve  from  the  canal  and  rupturing 
the  smaller  branches ;  carry  backward  around  the  nerve  as  far  as  possible  a 
strong  silk  ligature  and  tie  it;  stretch  the  nerve  by  strong  traction  on  the 
string ;  carry  along  the  under  surface  of  the  nerve  in  the  course  of  the  hook 
a  fine  pair  of  short-bladed,  blunt-pointed  scissors  sharply  curved  on  the 
flat ;  cut  the  nerve  as  close  to  the  foramen  as  possible,  and  remove  it ;  arrest 
haemorrhage,  remove  the  spatula,  and  allow  the  contents  of  the  orbit  to 
return  to  the  natural  position;  close  the  wound  and  apply  a  soft  compress 
to  the  eye  and  wound,  and  fasten  in  place  with  a  bandage. 

The  Precautions. — The  only  bleeding  of  any  account  comes  from  the 
infra-orbital  vessels,  and  this  can  be  easily  controlled  with  sponge  pressure. 
The  periosteum  beneath  the  orbital  plate  must  not  be  torn,  since  blood  will 
then  escape  into  the  antrum  of  Highmore.  The  manipulation  of  the  tissues 
of  the  spheno-maxillary  fossa  should  be  practiced  with  care  to  avoid  injury 
of  the  internal  maxillary  artery,  causing  haemorrhage  which  may  require 
ligature  of  the  external  carotid  to  arrest.  The  optic  nerve,  lying  some  dis- 
tance above  and  to  the  inner  side,  should  be  carefully  avoided. 

The  Remarks. — If  the  hook  have  an  advancing  cutting  border  calculated 
to  sever  the  branches  of  the  nerve  (Fig.  310)  at  their  origin,  then  the  nerve 
can  be  removed  back  to  the  foramen  with  no  danger  to  the  contiguous  tis- 
sues. In  this  instance  the  ganglion  is  not  removed,  but  its  branches  and 
those  going  to  the  superior  maxilla  are  severed.  Subconjunctival  ecchy- 
mosis  of  a  moderate  amount  appears,  but  is  rapidly  absorbed,  and  the  parts 
resume  their  usual  appearance  in  a  few  days,  only  a  trivial  cicatrix  re- 
maining at  the  seat  of  incision.  If  the  nerve  be  divided  behind  the  roots 
of  the  ganglion  and  firm  traction  be  made,  the  ganglion  and  its  branches 
are  stretched,  and  perhaps  the  ganglion  may  be  drawn  into  the  orbit  and  re- 
moved along  with  the  nerve.     The  disfigurement  from  this  operation  is 

trivial;  and  the  technique  is 
simple  and  attended  with  lit- 

Fig.  310.-Author's  curved  cutting  hook.  ^^^  ^^^^^^  ^^^  perplexity.   In 

the  experience  and  observation 
of  the  author  the  outcome  also  is  quite  as  favorable  as  when  the  ganglion 
is  removed.    Inasmuch  as  some  doubt  exists  as  to  whether  the  benefit  comes 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


281 


from  removal  of  the  ganglion  or  the  nerve  trunk  associated  with  it,  it  seems 
wise  to  cultivate  this  the  simpler  method  and  estahlish  its  status  rather  than 
practice  the  latter  and  graver  one  with  an  unwarranted  faith. 

The  foUoiving  operations  have  the  decided  advantage  of  heing  applical)le 
to  the  surgical  treatment  of  both  the  first  and  second  portions  of  the  nerve 
and  also  of  Meckel's  ganglion : 

Koclier's  Operation. — Make  an  incision  from  a  point  located  about  a 
quarter  of  an  inch  below  the  bony  margin  of  the  orbit  and  half  an  inch 
inside  the  infra-orbital  foramen,  obliquely  downward  and  outward  to  the 
lower  part  of  the  body  of  the  malar  bone,  as  far  as  the  zygomatic  arch  ( Fig. 
308,  a,h)  ;  divide  the  periosteum  between  the  lower  border  of  the  orbicularis 
palpebrarum  and  the  origin  of  the  levator  labii  superioris  muscles;  detach 
the  periosteum  upward  and  downward,  exposing  the  infra-orbital  nerve, 


LINE  OF  DIVISION  0F\ 
WE  ZYGOMATIC  ARCHJ 

ZYGOMATICUsl 
MAl/.M.(DETACHED).J 

ORIGIN  OF  ANT  BORDERI 
OF  MA55ETER.  ] 


Fig.  311. — Resection  of  the  second  division  of  the  trifacial  nerve. 


which  is  liberated  and  secured  with  a  ligature.  Draw  the  zygomatic  mus- 
cles downward  and  detach  the  anterior  fibres  of  the  masseter  from  the  malar 
bone;  elevate  the  periosteum  from  the  outer  and  inner  surfaces  of  the  ma- 
lar bone;  bare  the  anterior  surface  of  the  malar  process  of  the  upper  jaw 
(Fig.  311)  to  the  infra-orbital  foramen  and  its  upper  surface  back  to  the 


282 


OPERATIVE  SURGERY. 


spheno-maxillary  fissure;  draw  the  upper  border  of  the  wound  upward,  so 
as  to  expose  the  fronto-malar  suture;  so  chisel  through  the  fronto-malar 
suture  toward  the  posterior  part  of  the  spheno-maxillary  fissure  that  its  up- 
per border,  the  orbital  process  of  the  malar,  a  portion  of  the  orbital  plate  of 


SUPERIOR 
MAXILLARY 


SPHENO-PALATINE  N: 


MALAR  WITH  IVE  UPPER] 
AND  OUTER  PART  OF  I 
THE  ANTRUM, TURNED  I 
OUTWARDS. 


Fig.  312. — Exposure  of  the  second  division  of  the  trifacial  at  the  foramen  ovale. 

the  sphenoid,  and  a  part  of  the  zygomatic  crest  can  be  raised ;  draw  up  the 
orbital  nerve  and  chisel  from  above  the  infra-orbital  canal  downward  and 
outward  (Figs.  311  and  312)  to  below  the  anterior  border  of  the  origin  of 
the  masseter,  then  upward  through  the  outer  wall  of  the  antrum,  so  as  to 
meet  posteriorly  the  preceding  division  of  the  orbital  structure,  thus  permit- 
ting the  outer  wall  of  the  orbit,  the  supero-external  wall  of  the  antrum,  and 
its  posterior  angle  to  remain  connected  with  the  malar  bone  when  the  latter 
is  pried  outward.  Dislocate  the  bony  mass  upward  and  outward  with  a 
strong  hook,  raising  the  orbital  fat  with  a  blunt  retractor ;  expose  backward 
to  the  foramen  rotundum  the  nerve ;  pass  a  small  hook  behind  the  descend- 
ing spheno-palatine  nerves  around  the  main  trunk,  which  can  then  be  di- 
vided or  twisted  out.  The  bony  flap  is  returned  to  and  fastened  in  place  by 
sutures,  and  the  borders  of  the  wound  are  closed  in  a  similar  manner.  With 
careful  adjustment  of  the  parts,  but  little  disfigurement  results. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  283 

The  Remarls. — The  incision  is  an  extension  to  that  for  exposure  of  the 
infra-orbital  nerve  (Fig.  308,  a,b).  The  infra-orbital  artery  may  be  pushed 
aside  or  ligatured,  as  seems  best. 

Carnochan-Chavasse  Operation. — Through  a  V-,  U-,  Y-,  or  I-shaped  in- 
cision (Fig.  308,  f),  the  center  corresponding  to  the  infra-orbital  foramen, 
expose  the  infra-orbital  nerves  at  that  point,  and  tie  a  silk  ligature  carefully 
around  them ;  raise  the  periosteum  from  the  bone  and  perforate  the  anterior 
wall  of  the  antrum,  including  the  floor  of  the  foramen,  with  a  trephine  or 
gouge  and  mallet,  making  the  opening  about  three  quarters  of  an  inch  in 
diameter  (Fig.  309,  A).  Make  an  opening  in  the  posterior  wall  of  the  antrum 
half  an  inch  in  diameter,  as  near  to  the  roof  as  possible,  in  a  similar  manner. 
Control  the  hasmorrhage  from  the  antrum  with  aseptic  gauze  packing  and 
from  the  soft  parts  with  ligatures ;  raise  the  periosteum  from  the  roof  of  the 
antrum  in  the  line  of  the  orbital  canal  till  the  canal  can  be  localized  with  a 
probe;  divide  the  mucous  membrane  of  the  roof  of  the  antrum  in  the  line 
of  the  canal  in  the  floor,  and  with  a  small,  short  chisel,  brad  awl,  or  with 
scissors,  break  through  the  floor  of  the  canal  from  before  backward,  draw- 
ing down  on  the  nerve,  with  the  string,  as  it  is  liberated  from  the  bony 
canal.  With  a  blunt  end  of  a  director,  guided  by  the  liberated  nerve,  gently 
disengage  the  second  j^ortion  of  the  nerve  from  the  tissues  of  the  spheno- 
maxillary fossa  back  to  the  foramen  rotundum  (Fig.  309,  B),  into  which  the 
point  of  the  instrument  can  be  readily  inserted.  After  a  thorough  stretch- 
ing the  nerve  is  divided  at  the  foramen  rotundum  with  sharp  curved  scissors. 
Gentle  traction  on  the  divided  nerve  brings  the  ganglion  (Fig.  309,  C)  for- 
ward into  the  antrum,  and,  after  division  of  its  branches  of  distribution,  the 
ganglion  is  drawn  away  with  the  nerve  which  is  about  two  inches  in  length. 
The  wound  cavity  is  packed  with  gauze  till  bleeding  is  arrested,  then  the 
gauze  is  removed,  the  wound  drained,  closed,  and  dressed  in  the  usual  man- 
ner. In  the  opinion  of  the  writer,  it  is  better  to  adopt  the  plan  of  Abbe  and 
pack  the  wound  with  gauze  for  eight  hours  to  control  haemorrhage  than  to 
take  much  time  in  arresting  hsemorrhage,  or  the  risk  of  orbital  infiltration 
from  persistent  oozing  of  blood,  especially  since  the  delayed  measures  of 
treatment,  sewing,  etc.,  will  cause  no  pain  after  division  of  the  nerve. 

The  Precautions. — Almost  invariably  severe  hasmorrhage  is  caused  by 
the  opening  of  the  posterior  wall  of  the  antrum,  due  to  the  rupture  of  vessels 
running  in  the  posterior  dental  canals  at  that  situation.  At  the  outset  this 
hsemorrhage  is  quite  brisk,  leading  one  for  the  moment  to  fear  injury  of  the 
internal  maxillary  artery ;  but  the  patient  application  of  firm  pressure  with 
sponge  or  gauze  checks  the  flow  and  reassures  the  surgeon.  If  care  be  not 
exercised  in  the  making  of  the  opening  at  the  posterior  wall  of  the  antrum 
the  internal  maxillary  artery  will  be  torn.  In  this  instance  the  bleeding 
will  be  both  severe  and  persistent,  and  can  be  more  wisely  and  surely  con- 
trolled by  prompt  ligature  of  the  external  carotid  than  by  any  other  means. 
The  antrum  must  be  well  lighted  during  operation,  if  the  surgeon  expects 
to  see  the  ganglion  or  to  remove  the  nerve  entirely  from  its  canal,  without 
dividing  it  in  the  attempt.  Although  the  electric  headlight  (Fig.  Ill)  is 
the  best  means  for  the  purpose,  still,  in  its  absence,  the  reflections  of  a 


284 


OPERATIVE  SUEGERY. 


laryngeal  mirror  will  be  of  great  service.  Thorough  drainage  of  the  wound 
is  necessary,  and  frequent  cleansing  as  well,  since  the  free  communication 
between  the  nasal  meatus  and  the  antrum  exposes  the  latter  to  infection. 

Lilcke  reached  the  spheno-maxillary  fossa  and  the  foramen  rotundum 
through  a  quadrangular-shaped  flap  limited  below  by  the  lower  border  of  the 
zygoma,  above  and  in  front  by  the  frontal  process  of  the  malar  bone,  and 
behind  by  a  vertical  line  an  inch  in  length  crossing  the  origin  of  the  zygoma. 
Divide  the  masseter  at  the  lower  border  of  the  zygoma,  saw  the  zygoma  at 
either  end,  turn  the  flap  upward,  remove  intervening  structures,  separate 
the  two  heads  of  the  external  pterygoid  muscle,  and  expose  and  resect 
the  nerve  at  the  point  of  exit  from  the  foramen.  Although  the  mas- 
seter muscle  is  united  thereafter  with  sutures,  it  does  not  unite  kindly, 
and  a  crippling  of  the  movements  of  the  jaw  from  this  cause  is  quite  sure 
to  follow.  Lbssen  was  led  by  this  sequel  to  advise  that  the  temporal  fascia  be 
divided  instead  of  the  masseter,  and  the  zygoma  turned  downward,  instead 
of  upward,  as  before,  and  the  divided  borders  of  the  temporal  fascia  united 
subsequently  with  sutures.  The  reversal  of  this  portion  of  the  original 
plan  obviates  the  crippling  effects  of  division  of  the  masseter  muscle.  Not 
a  few  modifications  contemplating  an  attack  on  the  nerve  from  this  quarter 
are  advised.  However,  while  the  opportunity  for  open  work  is  often  en- 
hanced by  these  methods,  still  they  are  severe  in  character  and  expose  large 
surfaces  to  the  action  of  the  suppurative  and  infective  processes  incident 
to  faulty  technique. 

The  Results. — Section  of  the  nerve  in  any  part  of  the  course  is  usually  of 
temporary  use  only,  and  it  should  not  be  done  except  with  that  understand- 
ing. Stretching  before  section  may  add  somewhat  to  the  time  of  exemption 
from  pain  in  many  instances,  and  stretching  alone  will  often  afford  relief. 
Removal  of  the  entire  infra-orbital  portion  of  the  nerve  is  of  much  greater 
benefit  than  the  removal  of  any  part  of  it,  as  in  the  latter  procedure  some 
of  the  dental  nerves  may  remain  behind,  and,  moreover,  regeneration  is 
prompter  in  this  than  in  the  former  instance.  Removal  of  the  entire  nerve 
with  or  without  the  ganglion  is  frequently  followed  by  cure,  and  merits  pro- 
fessional confidence  and  prompt  action. 


Number 

of 

cases. 

DURATION  OF  RELIEF. 

6  months. 

6-12  mos. 

1-2  years. 

2-3  years. 

3  years. 

Nerve  and  ganglion  removed.  . . . 
Nerve  only  removed 

26 
26 

5 
4 

3 

7 

9 

7 

6 
3 

3 
5 

Total 

52 

9 

10 

16 

9 

8 

— Fowler. 
THIED    DIVISION"    OF   THE   TRIFACIAL   NERVE. 

The  intracranial  and  extracranial  portions  of  the  third  division  of  the 
fifth  nerve,  together  with  the  dental,  lingual,  auriculo-temporal  and  buccal 
branches,  are  each  amenable  to  surgical  procedure. 

TTie  Inferior  Dental  Nerve  (Fig.  309). — The  inferior  dental  nerve  is  the 
largest  of  the  branches  of  the  third  division.  It  passes  downward,  along  with. 


OPERATIONS   ON  THE   NERVOUS  SYSTEM.  285 

at  the  front,  and  to  the  inner  side  of  the  inferior  maxillary  vessels,  beneath 
the  external  pterygoid  muscle,  then  between  the  internal  lateral  ligament 
and  the  ramus  of  the  jaw  to  the  dental  foramen.  It  passes  forward  in  the 
dental  canal  of  the  lower  jaw,  supplying  the  teeth,  and  finally  terminates  at 
the  mental  foramen  in  the  incisor  and  mental  branches.  The  inferior  den- 
tal nerve  can  be  exposed  at  three  situations :  1,  before  entering  the  dental 
foramen ;  2,  in  the  dental  canal ;  3,  at  the  mental  foramen.  Operation  at 
the  first  situation  is  the  only  one  of  the  three  methods  that  affords  the 
patient  satisfactory  relief.  At  this  situation  the  nerve  can  be  reached  by 
either  of  two  methods,  known  respectively  as  the  internal  or  buccal  route, 
and  the  external  or  facial  route. 

TJie  Internal  or  Buccal  Route. — Although  the  nerve  is  deeply  situated  in 
the  mouth,  yet  it  has  superficial  and  deep  guides  that  lead  to  it  unerringly. 

The  superficial  guides  are  the  anterior  border  of  the  ascending  ramus  of 
the  jaw  and  of  the  internal  pterygoid  muscle.  These  guides  can  be  easily 
distinguished  with  the  finger  through  the  widely  opened  mouth,  before  the 
operation. 

The  deep  guides  are  the  spine  of  Spix  and  the  internal  lateral  ligament 
which  is  inserted  into  the  spine.  Although  the  deep  guides  can  be  located 
with  the  finger  before  the  operation,  still  they  are  of  far  greater  significance 
after  the  making  of  the  primary  incision.  After  a  thorough  cleansing  of  the 
teeth  and  buccal  mucous  membrane  at  the  site  of  the  operation,  with  anti- 
septics and  scrubbing,  the  patient  is  anaesthetized,  placed  in  a  good  sunlight, 
or  an  electric  headlight  is  provided. 

The  Operation  (Paravicini). — Fix  the  mouth  widely  open  with  a  Den- 
hard  (Fig.  4),  Goodwillie  (Fig.  848,  /),  or  extemporized  mouth  gag,  placed  at 
the  side  opposite  to  the  operation.  With  two  narrow  retractors  pull  the  cheek 
backward  and  away  from  the  field  of  operation ;  pull  the  tongue  to  the  oppo- 
site direction  ;  locate  the  inner  edge  of  the  anterior  border  of  the  ascending 
ramus  of  the  jaw,  and  of  the  internal  pterygoid  muscle  with  the  finger; 
make  an  incision  through  the  mucous  membrane  between  these  guides,  about 
an  inch  in  length,  close  to  the  bone,  with  a  long-handled  scalpel.  Separate 
the  tissues  with  a  firm  spatula  or  a  small  periosteal  elevator,  aided  by  the 
finger,  from  the  bone  down  to  the  spine  of  Spix.  The  periosteum  is  not  dis- 
turbed. The  spine  of  Spix  is  usually  well  developed  and,  consequently,  is 
easily  located  at  this  time,  along  with  the  internal  lateral  ligament  which  is 
inserted  into  it.  At  the  base  of  the  spine  the  foramen  can  be  felt,  and  occa- 
sionally also  the  nerve  and  vessels  as  they  enter  it.  If  additional  space  be  re- 
quired divide  the  internal  lateral  ligament  with  scissors ;  draw  inward  the  in- 
ternal pterygoid  with  a  retractor ;  sponge  out  the  wound  cavity  and  expose  it 
to  a  strong  light.  A  blunt  hook,  curved  at  the  side,  or  an  aneurismal  needle, 
curved  in  the  same  manner,  is  passed  into  the  wound,  the  nerve  hooked  up,  if 
possible  at  a  point  half  an  inch  from  the  foramen,  and  drawn  forward.  Ke- 
move  the  artery  from  the  hook  if  included  with  the  nerve,  and  then  pass 
around  the  nerve  at  this  point  a  strong  silken  ligature,  and  tie  it  firmly  to 
the  nerve.  The  nerve  is  then  stretched  by  means  of  the  ligature  and  divided 
with  scissors  above  and  as  near  to  the  internal  maxillary  artery  as  is  safe. 


286 


OPERATIVE  SURaERY. 


The  lower  end  is  then  stretched  and  cut  off  at  the  foramen  in  the  same 
manner,  carefully  avoiding  the  dental  artery.  About  three  quarters  of  an 
inch  to  an  inch  in  length  can  thus  be  resected. 

The  Precautions. — The  lingual  nerve,  which  may  be  mistaken  for  the 
dental,  can  be  easily  diiferentiated  by  making  upward  traction  ;  then,  if  the 
latter  be  the  one  grasped,  firm  resistance  is  noted ;  if  the  former,  the  tongue 
and  its  contiguous  tissues  are  easily  and  freely  moved  by  the  traction.  The 
dental  nerve  may  be  ru]3tured  if  too  severe  traction  be  made  upon  it;  a 


AURICULO-TEMPORAL  A 
TEMPORAL  A. AND  V 


{ORBICULARIS 
ORIS  M. 


^MASSETER    M. 
•-OUTER  SURFACE  OF JAVJ 
MASSETER  AT  ANGLE  OF  JAV 
r'lCIAL    A. 


\ 

Fig.  313. — Resection  of  inferior  dental  nerve.     The  temporal  and  facial  arteries. 

resistance  of  from  ten  to  fifteen  pounds  is  safely  borne.  Division  of  the 
inferior  dental  or  of  the  internal  maxillary  arteries  will  cause  troublesome 
hasmorrhage.  Pressure  of  the  vessel  against  the  bone  will  control  the  former ; 
for  control  of  the  latter,  ligature  of  the  external  carotid  may  be  necessary. 

The  Comments. — During  the  after-treatment  the  mouth  should  be  kept 
thoroughly  cleansed  to  obviate  or  lessen,  as  far  as  possible,  subsequent  in- 
flammatory action  at  the  seat  of  the  operation.  If  suppuration  occur,  we 
regard  it  wise  to  establish  drainage  externally  by  means  of  a  small  rubber 
tube  carried  through  an  opening  made  from  the  bottom  of  the  wound  out 
near  the  angle  of  the  jaw,  by  means  of  a  curved,  sharp-pointed  scissors  thrust 
while  closed  through  the  tissues  at  this  situation.  The  patient  should  be 
thoroughly  anaesthetized  before  the  operation  is  commenced,  or  his  struggles 
will  delay  the  procedure,  cause  undue  injury  of  the  soft  parts,  and  otherwise 
embarrass  the  surgeon.  Since  the  operation  is  a  troublesome  and  annoying 
one  at  the  best,  the  surgeon  should  claim  for  his  support  the  advantage  of 
every  resource  at  his  command. 

The  External  or  Facial  Route. — In  this  route  an  opening  is  made  through 
the  cheek,  and  sometimes  through  the  ascending  ramus  of  the  jaw,  at  a  point 
corresponding  to  the  situation  of  the  inferior  dental  foramen.  The  guides  to 
the  operation  are  the  masseter  muscle,  the  angle  of  the  jaw,  and  the  anterior 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  28Y 

and  posterior  borders  of  the  ascending  ramus.  The  chief  objections  to  the 
external  route  are:  1,  the  difficulty  in  dividing  satisfactorily  the  soft  parts 
without  injury  of  some  of  the  infra-maxillary  branches  of  the  facial  nerve ; 
2,  the  crippling  of  the  jaw  that  may  follow  interference  with  the  masseter 
muscle;  3,  the  production  of  an  objectionable  cicatrix.  The  first  objection 
can  be  met  by  carefully  locating  the  line  of  incision.  Keen  recommends 
that  an  incision  two  inches  in  length  be  made  along  the  lower  border  of  the 
jaw,  beginning  a  little  behind  the  angle  (Fig.  315,  d),  and  so  located  as  to 
reduce  to  a  minimum  the  expanse  of  the  scar.  Through  this  incision  the 
masseter  muscle  is  raised  from  the  ramus  with  a  sharp  periosteal  elevator. 
The  tissues  are  pulled  aside  and  a  half -inch  opening  is  made  with  a  trephine 
one  inch  and  a  quarter  above  the  angle  and  directly  below  the  sigmoid  notch — 
i.  e.,  at  about  the  middle  of  the  perpendicular  ramus  of  the  jaw  (Fig.  313). 
Through  this  opening  the  nerve  is  exposed  as  it  enters  the  foramen,  is  hooked 
up  with  a  needle  and  stretched,  and  as  much  as  possible  of  it  removed  with- 
out injury  to  the  contiguous  tissues.  If  removal  of  the  nerve  farther  for- 
ward be  desired,  the  incision  can  be  extended  anteriorly,  even  to  the  mental 
foramen  (d,  f),  after  tying,  or  by  careful  avoidance  of  the  facial  vessels. 
Kiihn,  through  an  incision  around  the  angle  of  the  jaw  corresponding  to  the 
borders  of  insertion  of  the  masseter  (Fig.  315,  e,  d)  muscle,  and  after  resect- 
ing a  portion  of  the  angle  of  the  jaw,  exposed  the  nerve  from  below.  Liicke, 
through  a  similar  incision,  raised  the  insertion  of  the  internal  pterygoid  and 
other  soft  parts  from  the  jaw  with  a  periosteotome,  until  the  nerve  could  be 
felt  with  the  finger,  when  it  was  hooked,  drawn  down  and  resected.  Horsley 
has  proposed  to  accomplish  the  purpose  by  raising  a  flap  composed  of  the 
skin  and  subcutaneous  tissue  only,  limited  behind  by  a  vertical  incision  ex- 
tending from  just  above  the  zygoma  to  the  angle  of  the  jaw,  followed  by  its 
continuance  forward  beneath  the  jaw  in  a  horizontal  direction  to  the  facial 
artery.  The  flap  is  lifted  and  turned  aside,  leaving  Stenson's  duct  and  the 
branches  of  the  facial  nerve  undisturbed.  The  masseteric  fascia  is  then  di- 
vided between  Stenson's  duct  and  the  temporo-facial  branch  of  the  facial 
nerve,  and  the  opening  increased  to  an  inch  and  a  quarter  in  diameter ;  the 
parotid  is  drawn  toward  the  ear,  and  the  situation  of  the  posterior  border  of 
the  jaw  defined.  Now  the  posterior  two  thirds  of  the  masseter  muscle  are 
divided,  and  the  outer  surface  of  the  bone  is  exposed  until  the  sigmoid  notch 
is  clearly  seen,  when,  with  the  aid  of  a  bone  drill,  trephine,  etc.,  the  sigmoid 
notch  is  prolonged  directly  downward  to  the  inferior  dental  foramen.  With 
this  method  the  nerve  can  be  followed  up  and  resected  to  within  one  third  of 
an  inch  of  the  foramen  ovale.  The  nerve  can  be  reached  promptly  from 
the  outer  surface  through  a  vertical  (Linhart)  (Fig.  315,  a)  or  U-shaped 
incision,  made  directly  down  to  the  hone,  beginning  just  below  Stenson's 
duct  and  extending  downward  about -two  inches.  The  periosteum  is  then 
raised  along  with  the  associated  masseteric  fibers,  sufficiently  to  expose  the 
center  of  the  ramus ;  the  soft  parts  are  drawn  aside  and  the  nerve  is  exposed 
at  the  foramen  by  aid  of  the  trephine,  or  farther  forward,  if  desired,  by  re- 
moval of  the  external  table  of  the  jaw  with  the  chisel  and  mallet.  In  either 
case  the  nerve  is  stretched  and  as  freely  resected  as  possible. 


288  OPERATIVE  SURGERY. 

The  Precautions. — The  external  incisions  expose  to  danger  Stenson's  duct 
and  the  branches  of  the  facial  nerve.  The  former  runs  forward  on  the  ex- 
ternal surface  of  the  masseter  to  the  buccinato  rmuscle,  which  it  enters  op- 
posite the  second  molar  tooth,  parallel  with,  and  a  finger's  breadth  below  the 
zygoma.  The  directions  of  the  branches  of  the  nerve  should  be  carefully 
studied  before  making  the  external  incision,  to  avoid  any  motor  paralysis 
of  the  face  that  may  follow  their  division.  On  opening  through  the  ramus 
of  the  jaw,  the  mylo-hyoid  nerve  may  be  mistaken  for  the  inferior  dental. 
However,  the  former  is  much  the  smaller,  and  if  pulled  upon  is  unfixed, 
and  enters  soft  intrabuccal  tissues,  while  the  latter  is  fixed  when  pulled 
upon,  as  it  supplies  bony  tissues.  The  separation  from  the  bone,  or  the 
division  of  the  fibers  of  the  masseter,  must  be  performed  carefully  and  asep- 
tically,  otherwise  the  advent  of  suppurative  processes  will  prolong  the  recov- 
ery and  impair  the  movements  of  the  jaw.  In  resections  of  this  nerve  at 
either  aspect  of  the  jaw,  the  divided  ends  should  be  turned  aside  or  tissues 
interposed  between  them  so  as  to  prevent  regenerative  union. 

The  inferior  dental  nerve  can  be  exposed  in  the  dental  canal  from  the 
inferior  dental  to  the  mental  foramen,  if  need  be,  by  making  a  free  incision 
down  to  the  bone  along  the  under  surface  of  the  jaw  (Fig.  315,  d,  /),then 
raising  the  soft  parts  along  with  the  periosteum  with  the  elevator,  drawing 
aside  the  flap,  and  exposing  the  nerve  in  the  canal  by  the  use  of  the  electro- 
motor trephine,  chisel  and  mallet,  etc.  The  exposure  of  the  nerve  here  is 
more  a  matter  of  labor  than  of  skill ;  the  final  removal,  however,  is  easily 
accomplished  with  scissors  and  forceps.  The  wound  should  be  closed 
promptly,  the  same  as  are  incised  wounds  in  other  situations.  If  undue 
violence  be  employed  in  the  use  of  the  chisel  and  mallet,  the  jaw  may  be 
fractured.  The  termination  of  the  inferior  dental  nerve  and  its  mental 
iratich  can  be  treated  surgically  by  exposure  of  them  at  the  mental  fora- 
men. In  stretching,  the  breaking  strain  of  the  mental  nerve  is  five  and  a 
half  pounds.  The  mental  nerve  escapes  from  the  mental  foramen  along 
with  the  mental  vessels,  opposite  to  the  interval  between  the  bicuspid  teeth 
of  the  same  side. 

The  Operation. — Draw  the  angle  of  the  mouth  downward  and  outward ; 
make  a  horizontal  incision  one  inch  in  length  at  the  buccal  fold,  with  the 
center  opposite  the  interval  before  mentioned,  through  the  mucous  mem- 
brane down  to  the  bone ;  raise  the  mucous  membrane  and  periosteum  with  a 
director,  so  as  to  expose  the  mental  foramen ;  dissect  out  the  nerve,  seize  and 
stretch  or  remove  it.  If  a  trephine  or  chisel  be  applied  to  the  jaw  posteriorly 
to  the  foramen,  and  the  outer  table  be  removed,  then  the  anterior  extremity 
of  the  inferior  dental  can  be  exposed  and  resected,  thus  exercising  some  com- 
mand over  the  incisive  branches  of  that  side. 

The  Lingual  or  Gustatory  Nerve. — The  lingual  nerve  is  the  sensory 
nerve  of  the  anterior  two  thirds  of  the  tongue.  It  is  often  treated  sur- 
gically for  the  relief  of  the  pain  and  sialorrhoea  incident  to  cancer  of  the 
tongue. 

The  Anatomical  Points. — The  nerve  passes  between  the  internal  pterygoid 
muscle  and  the  internal  lateral  ligament  of  the  lower  jaw,  and  is  located 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  289 

internally  and  anteriorly  to  the  inferior  dental  nerve.  Although  deeply 
placed  at  first,  it  becomes  quite  superficial  as  it  reaches  the  floor  of  the 
mouth.  The  guides  to  the  nerve  are  the  last  molar  tooth  of  the  lower  jaw 
and  the  pterygo-maxillary  ligament.  The  nerve  is  situated  half  an  inch 
below  and  behind  the  last  molar  tooth,  and  in  front  of  the  pterygo-maxillary 
ligament,  where,  with  the  mouth  widely  opened  and  the  tongue  placed  on 
the  stretch,  it  can  be  felt  as  it  passes  beneath  the  mucous  membrane  to  gain 
the  anterior  portion  of  the  tongue.  The  pterygo-maxillary  ligament  is 
easily  noted  beneath  the  mucous  membrane  just  inside  the  coronoid  process, 
and  it  is  somewhat  tightened  by  opening  the  mouth  widely. 

The  lingual  nerve  can  be  reached  by  either  the  intrabuccal  or  extra- 
buccal  routes,  the  former  being  employed  much  the  more  frequently. 

The  Operation  (intrabuccal  route). — Open  the  mouth  amply  with  the 
gag;  draw  the  cheek  aside  with  the  retractor,  and  the  tongue  forward  and  to 
the  opposite  side  with  a  tongue  forceps ;  indicate  the  location  of  the  nerve 
with  the  index  finger  placed  at  the  point  of  insertion  of  the  pterygo-maxil- 
lary ligament,  then  with  a  scalpel  make  a  longitudinal  incision  one  inch  in 
length  through  the  mucous  membrane  from  this  point  forward,  or  make  a 
vertical  one  of  the  same  length  over  the  nerve  midway  between  the  tongue 
and  the  gum  at  the  root  of  the  last  molar  tooth,  thus  easily  exposing  the 
nerve,  which  can  be  drawn  forward  with  a  hook  and  stretched  or  resected. 
Neurotomy  may  be  practiced  on  this  nerve  by  means  of  a  bistoury  passed 
through  the  mucous  membrane  at  a  point  three  quarters  of  an  inch  behind 
and  below  the  last  molar  tooth,  and  curved  forward  and  upward  toward  the 
jaw  on  an  imaginary  line  extending  between  the  last  molar  tooth  and  the 
angle  of  the  jaw  for  the  distance  of  half  an  inch.  The  comparatively 
brief  relief  afforded  by  this  method  does  not  commend  its  employment 
except  as  a  temporary  expedient. 

The  Operation  (extrabuccal  route). — The  nerve  can  be  reached  through 
the  submaxillary  triangle  by  an  incision  extending  from  the  anterior  border 
of  the  masseter  muscle  to  near  the  symphysis  menti.  The  facial  artery  is 
exposed  but  not  tied ;  the  submaxillary  gland  is  liberated  of  its  facial  con- 
nections and  drawn  downward  and  forward,  thus  exposing  the  mylo-hyoid 
vessels  and  nerves  as  they  lie  on  the  mylo-hyoid  muscle.  This  muscle  is 
drawn  forward  by  means  of  a  retractor  applied  to  the  posterior  border.  The 
lingual  artery  is  displaced  downward,  and  the  lingual  nerve  then  appears  at 
the  posterior  border  of  the  muscle,  lying  beneath  the  mucous  membrane  near 
to  the  last  molar  tooth.  This  method  of  procedure  is  not  advisable  on  ac- 
count of  the  intricate  technique,  unless  the  lingual  artery  is  to  be  tied  for 
malignant  disease  of  the  tongue,  when  the  nerve  can  be  wisely  resected 
through  the  same  opening.  This  nerve  can  be  reached  from  without  by  the 
same  procedures  as  those  addressed  to  the  inferior  dental  (page  285). 

The  auriculo-teniporal  nerve  is  easil)^  exposed,  as  it  crosses  the  base  of  the 
zygoma  through  a  short  vertical  incision  made  immediately  in  front  of  the 
pinna  (Fig.  313).  Here  the  nerve  lies  behind  the  temporal  artery,  the  pul- 
sation of  which  serves  as  an  excellent  guide  to  it.  Care  should  be  exercised 
in  the  dissection  at  this  point,  otherwise  the  parotid  gland  will  bo  injured. 


290  OPERATIVE  SURGERY. 

The  Buccal  Nerve. — The  buccal  nerve  can  be  exposed  through  either  a7i 
intrahiiccal  or  extrabuccal  incision,  the  former  being  the  preferable.  Two 
methods  of  intrabuccal  exposure  are  noted,  hi  one  the  nerve  is  bared  as 
it  reaches  the  buccinator  muscle,  through  a  vertical  incision  in  the  mu- 
cous membrane  and  fibers  of  the  muscle,  made  with  its  center  at  the  mid- 
dle of  the  anterior  border  of  the  ascending  ramus  of  the  lower  jaw.  The 
nerve  at  this  situation  divides  into  two  branches ;  therefore  care  must  be  ex- 
ercised in  observation  lest  one  or  both  branches,  and  even  the  trunk  itself, 
escape  notice.  The  operation  will  be  futile  unless  the  trunk  of  the  nerve 
be  secured  and  treated.  In  the  other  method  open  the  mouth  widely  and 
make  an  incision  along  the  anterior  margin  of  the  coronoid  process  through 
the  mucous  membrane,  and  grasp  the  nerve  as  it  crosses  this  margin  of  the 
process.  The  fact  that  the  nerve  sometimes  reaches  the  buccinator  by  pass- 
ing through  the  temporal  muscle  invests  the  latter  method  with  a  reason- 
able degree  of  uncertainty,  since  then  the  nerve  is  not  found  at  the  anterior 
border  of  the  coronoid  process. 

The  Extrabuccal  Method  (Zuckerkandl). — The  extrabuccal  method  con- 
sists in  making  a  short  incision  forward  from  the  anterior  margin  of  the 
masseter  muscle  between  the  zygoma  and  Stenson's  duct  down  to  the  fatty 
cushion  of  the  cheek.  The  cheek  fat  is  pushed  aside  so  as  to  expose  the 
anterior  border  of  the  coronoid  process  along  the  inner  surface  of  which  the 
nerve  is  found  to  pass.  This  method  of  procedure  exposes  to  the  danger  of 
injury  the  transverse  facial  artery  and  branches  of  the  facial  nerve. 

The  Results. — The  results  of  division  and  excision  are  similar  here  to 
those  of  the  preceding  trials  and  like  those  results  justify  the  trial  before  the 
others  of  graver  import  are  attempted.  Stewart,  of  Montreal,  contributes  the 
following  conclusions  regarding  nerve-stretching  in  inveterate  trigeminal 
neuralgia :  "  1.  Nerve-stretching  gives  either  complete  or  great  relief  in 
the  majority  of  cases.  2.  Relief  is  not  permanent  in  more  than  five  per 
cent  of  cases.  3.  If  pain  should  return,  the  operation  should  be  repeated, 
even  several  times,  before  resorting  to  neurectomy  or  ligature  of  the  com- 
mon carotid.  4.  If  the  pain  is  not  strictly  and  always  limited  to  one 
branch  of  the  nerve,  several  branches  should  be  stretched.  5.  As  relief 
does  not  always  immediately  follow  stretching,  a  second  operation  should 
not  be  undertaken  until  some  time  has  elapsed." 

TEUNK  OF  THE  NERVE  AT  THE  FORAMEN  OVALE. 

The  important  anatomical  points  connected  with  the  nerve  at  this  situa- 
tion are :  1,  the  large  size — larger  than  either  of  the  other  divisions  of  the 
fifth ;  2,  the  junction  of  the  motor  and  sensory  roots  just  after  leaving 
the  foramen  ovale ;  3,  the  numerous  branches  given  off  from  the  common 
trunk  after  the  junction ;  4,  the  relations  of  the  middle  and  small  meningeal 
arteries,  the  external  pterygoid  muscle  and  pterygoid  plexus  of  veins  and 
internal  maxillary  artery,  all  of  which  should  be  carefully  studied  before 
attempting  the  operation.  The  localization  of  the  foramen  ovale  is  a  mat- 
ter of  the  greatest  importance.  Bony  and  muscular  guides  indicate  the 
situation  with  practical  accuracy.     The  junction  of  the  zygoma  and  emi- 


OPERATIONS  ON  TPIE   NERVOUS  SYSTEM. 


291 


nentia  articularis  is  located  about  an  inch  and  a  quarter  directly  outside 
of  the  foramen ;  the  free  edge  of  the  external  pterygoid  plate  at  the  root 
of  the  process  is  just  in  front  of  the  opening ;  the  pterygoid  muscles  cover 
in  the  foramen  and  the  trunk  of  the  nerve.  If  the  finger  be  inserted  into 
the   zygomatic   fossa    in  front    of   the    eminentia   articularis,  the   nerve  is 


Fig.  314. — Incision  for  exposure  of  third  division  of  trifacial  nerve  at  foramen  ovale  and 

of  facial  nerve, 

found  between  the  base  of  the  external  pterygoid  plate  and  the  spinous 
process  of  the  sphenoid,  either  of  which  can  be  easily  felt.  If  now,  as 
MacCormac  says,  "a  knife  be  passed  along  the  outer  surface  of  the 
greater  wing  of  the  sphenoid  and  between  the  middle  meningeal  artery 
and  the  nerve  trunk,  the  latter  may  be  divided  from  behind  forward  with 
perfect  safety."  However,  if  the  middle  meningeal  artery  escape  injury 
at  this  time,  the  small  meningeal  and  the  lesser  superficial  petrosal  nerve 
will  quite  surely  be  divided  along  with  the  motor  root  of  the  third  division. 
Motor  paralysis  of  the  muscles  of  mastication,  the  mylo-hyoid  and  anterior 
belly  of  the  digastric,  the  tensor  tympani  and  tensor  palati  muscles,  on 
the  side  of  the  section,  will  follow,  attended  with  loss  of  sensation  and  relief 
from  pain  if  the  central  end  of  the  divided  nerve  be  not  involved.  How- 
ever, the  motor  paralysis  has  not  sufficient  significance  to  coutraindicate 
the  operation. 


292 


OPERATIVE  SURGERY. 


Koclier's  Operation. — An  incision  beginning  just  behind  the  frontal 
process  of  the  malar  bone  is  carried  obliquely  downward  and  backward  to 
the  posterior  extremity  of  the  zygomatic  arch^  thence  upward  and  backward 
in  front  of  the  ear  at  nearly  right  angle  to  the  first  part  of  the  incision 
(Fig.  314),  dividing  fibers  of  the  orbicularis,  the  superficial  and  temporal 
fasciae  at  the  first,  and  all  tissues  down  to  the  bone  at  the  second  part  of  the 
incision.  Draw  the  borders  of  the  wound  apart;  expose  the  malar  bone 
behind  the  frontal  process  and  divide  it  vertically  with  a  chisel;  divide  the 
zygoma  posteriorly  close  to  its  anterior  root,  and  draw  the  fragment  down 


SAWN  SURFACES 
OFTHEiROOT  or 
THE  ZYGOMA 


Fig.  315. — Exposure  of  the  third  division  of  the  trifacial  in  its  course  and  at  the 

foramen  ovale. 


with  a  strong  hook ;  expose  the  outer  surface  of  the  temporal  muscle,  sepa- 
rate its  posterior  and  lower  border  from  the  skull,  and  draw  it  forward  with 
a  hook  (Fig.  315)  ;  divide  the  periosteum  from  the  anterior  edge  of  the 
root  of  the  zygoma  forward  along  the  pterygoid  ridge;  detach  with  it  the 
soft  parts  from  the  under  surface  of  the  great  wing  of  the  sphenoid  down 
to  the  base  of  the  pterygoid  process  with  a  periosteotome ;  locate  the  fora- 
men ovale  with  the  finger,  and  expose  the  nerve  to  view,  carefully  avoid- 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  293 

ing  the  middle  meningeal  artery  lying  posteriorly;  stretch  and  resect  the 
nerve;  place  and  wire  in  position  the  zygomatic  arch,  unite  the  borders  of 
the  wound,  and  dress  antiseptically.  This  plan  of  procedure  exposes  the 
vessels  to  the  minimum  amount  of  danger,  and  therefore  gives  rise  to  the 
least  amount  of  haemorrhage. 

Pancoast's  Operation. — Make  a  horizontal  incision,  near  to  where  the 
ramus  joins  the  body,  the  entire  breadth  of  the  perpendicular  ramus  of  the 
lower  jaw  down  to  the  bone;  connect  to  the  extremities  of  this  incision 
two  perpendicular  ones  of  a  similar  depth  as  the  first,  carried  upward  to 
Stenson's  duct,  then  superficially  from  that  point  to  the  zygoma  and  malar 
bone,  carefully  avoiding  the  duct  (Fig.  315,  h) ;  raise  the  flap  and  saw 
through  the  coronoid  process  at  the  base,  and  remove  the  fragment  along 
with  the  insertion  of  the  temporal  muscle ;  push  the  temporal  muscle  upward 
beneath  the  zygoma,  and  take  away  the  fatty  tissue  thus  exposed  to  view ;  tie 
the  internal  maxillary  artery  as  it  passes  close  to  the  internal  surface  of  the 
neck  of  the  jaw  in  two  places  and  divide  the  nerve  between  the  ligatures ; 
detach  the  upper  head  of  the  external  pterygoid  from  the  great  wing  of  the 
sphenoid  with  the  finger;  check  haemorrhage  and  expose  the  nerve  at  the 
bottom  of  the  fossa  and  divide  it  with  scissors  close  to  the  bone. 

Kronleins  Modification. — In  the  modification  of  Kronlein  the  temporal 
fossa  is  uncovered  by  means  of  two  flaps,  a  superficial  and  a  deep  one.  The 
former  corresponds  in  all  essential  respects  to  that  of  Pancoast.  The  latter 
is  of  similar  shape  and  dimensions  as  the  former,  is  composed  of  masseter 
muscle  and  the  zygoma,  the  bone  being  sawn  across  anteriorly  downward 
and  forward  through  the  zygomatic  process  of  the  malar  at  the  point  of 
articulation,  and  posteriori}^,  immediately  in  front  of  the  articular  tubercle, 
and  the  whole  reflected  downward  on  the  masseter  as  a  hinge.  The  inner 
flap  is  stretched  rather  than  divided,  to  avoid  injury  of  Stenson's  duct  and 
the  facial  nerve.  The  infra-maxillary  nerve  is  then  exposed  and  resected 
without  loss  of  other  essential  structure.  Through  the  pterygo-maxillary 
fissure  the  second  division  is  then  resected  with  a  thin  cutting  instrument, 
and  if  possible  without  widening  the  fissure  by  chiseling.  The  separated 
structures  are  returned  into  position  and  fastened  there;  thus  the  aim  is 
attained  without  the  sacrifice  of  an  essential  part. 

C redes  Modification. — In  C rede's  modification  the  nerve  is  reached 
through  the  sigmoid  notch  while  the  temporal  muscle  is  drawn  backward 
with  a  blunt  hook.  The  internal  maxillary  artery  is  not  seen.  In  other 
respects  the  procedures  are  similar. 

Salzers  Modification. — In  Salzer's  modification  the  free  end  of  the  fiap  is 
formed  a  finger's  breadth  above  the  zygoma,  going  through  the  temporal  mus- 
cle down  to  the  bone.  After  the  arrest  of  ha?morrhage,  the  flap  is  raised, 
including  the  zygoma,  and  carried  down  sufficiently  to  expose  the  roof  of  the 
zygomatic  fossa.  The  upper  part  of  the  external  pterygoid  muscle  is  removed 
from  the  sphenoid  with  the  finger,  as  before,  and  the  nerve  is  exposed. 

Mixter,  by  means  of  a  curved  incision  commencing  about  half  an  inch 
below  the  zygomatic  process  of  the  malar  bone  and  going  upward  along  the 
posterior  border  of  this  bone  and  of  the  external  angular  process  of  the 
21 


294:  OPERATIVE  SURGERY. 

frontal  bone  to  the  temporal  ridge,  tliience  along  the  temporal  ridge,  down- 
ward in  front  of  the  ear  to  a  point  half  an  inch  below  the  zygoma,  followed 
by  severing  of  the  zygoma  at  each  end,  forms  a  flap  which  when  drawn 
downward,  attended  with  separation  of  the  temporal  and  pterygoid  muscles, 
permits  of  a  quite  ready  exposure  of  the  superior  and  inferior  maxillary 
nerves  as  they  escape  from  their  respective  foramina  at  the  base  of  the  skull. 
If  the  former  nerve  and  its  foramen  of  exit  is  to  be  exposed  the  temporal 
muscle  is  drawn  strongly  forward,  the  jaw  depressed,  and  the  pterygo-max- 
illary  fissure  located  by  passing  the  finger  along  the  posterior  wall  of  the 
superior  maxilla  to  the  projecting  spur  at  the  upper  end  of  the  external 
pterygoid  plate,  which  latter  may  be  cautiously  chiseled  off,  thus  better  ex- 
posing the  nerve  as  it  crosses  the  spheno-maxillary  fossa  just  above  Meckel's 
ganglion.  If  the  latter  nerve  and  its  foramen  of  exit  are  to  be  exposed,  the 
temporal  muscle  is  drawn  forward,  the  jaw  relaxed,  the  pterygoid  muscles 
so  displaced  by  traction  as  to  permit  the  finger  to  pass  upward  along  the 
external  pterygoid  plate  to  a  point  just  posterior  and  external  to  the  base  of 
the  plate  where  directly  inward,  at  a  distance  of  about  an  inch  and  a  half 
from  the  zygoma,  the  nerve  will  be  felt  as  it  escapes  from  the  foramen  ovale. 

The  Comments. — It  will  be  noted  that  the  details  of  this  plan  are  not 
essentially  distinctive  from  those  just  preceding,  directed  to  similar  pur- 
poses. And,  too,  they  may  be  varied  in  technique  by  acceptable  features  of 
those  methods  when  desirable.  The  further  division  of  the  zygoma  should 
be  made  at  a  safe  distance  anterior  to  the  eminentia  articularis  to  avoid 
the  joint. 

The  Precautions. — The  internal  maxillary,  the  meningeal  vessels,  and 
pterygoid  plexus  -of  veins  must  be  carefully  avoided.  If  exposed  they 
should  be  ligatured  at  two  places  and  severed  between  the  ligatures  to  avoid 
the  possibility  of  hasmorrhage.  The  middle  meningeal  is  sometimes  so 
closely  associated  with  the  nerve  as  to  be  scarcely  separable  from  it.  In 
such  cases  the  contiguity  can  be  determined  with  the  finger  by  noting  the 
pulsation.  In  fact,  in  each  instance  the  artery  should  be  thus  located,  if 
possible,  before  the  nerve  is  divided.  Pressure,  direct  ligature,  and  ligature 
of  the  internal  maxillary  and  external  carotid  are  the  means  for  arrest  of 
haemorrhage.  The  average  relation  of  this  nerve  and  artery  will  aippear  in 
connection  with  intracranial  operations  on  the  nerve.  The  facial  nerve  and 
Stenson's  duct  have  been  mentioned  sufficiently  already  to  call  for  the  exer- 
cise of  extreme  caution  in  this  regard  in  the  operative  technique.  The 
nerve  should  be  divided  close  to  the  bone,  to  secure  severance  of  all  the 
branches.  Free  excision  should  be  practiced,  and  the  proximal  end  pushed 
upward  into  the  foramen,  when  feasible,  to  secure  as  wide  separation  of  the 
divided  ends  as  possible. 

The  treatment  consists  in  closing  the  wound  after  bleeding  is  completely 
arrested,  and  applying  a  firm  compress  to  it;  then  dress  antiseptically.  If 
oozing  persist,  tampon  with  gauze  and  unite  borders,  leaving  room  for  with- 
drawal of  the  tampon. 

The  Results. — The  danger  to  life  is  not  significant  in  this  operation,  un- 
less infection  of  the  wound  or  severe  haemorrhage  supervene.     Therefore 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  295 

asepsis  should  be  practiced  sedulously  and  all  bleeding  controlled.     The 
curative  outcome  of  the  operation  is  not  infrequently  discouraging. 


INTRACRANIAL  NEURECTOMY, 

The  operation  of  intracranial  nevirectomy  is  employed  for  the  purpose 
of  curing  intractable  cases  of  trigeminal  neuralgia  that  have  resisted  medici- 
nal and  other  operative  means  of  relief.  The  operation  contemplates  the 
intracranial  section  of  the  second  and  third  divisions  of  the  trifacial  nerve 
at  the  points  of  entry  to  the  foramina  of  escape,  the  removal  of  the  proxi- 
mal ends  of  the  divided  nerves,  and  excision  of  the  ganglion  itself.  Two 
methods  of  attainment  of  these  objects  are  frequently  practiced,  one  devised 
by  Eose,  the  other  by  Hartley  and  Krause.  In  both  the  operation  field  is 
extra-dural. 

Rose's  Method. — The  patient  is  prepared  by  giving  proper  attention  to 
the  bowels,  stomach,  kidneys,  etc.  The  side  of  the  head  corresponding 
to  the  side  of  the  face  involved  is  carefully  purified,  the  ear  cleansed  and 
plugged  with  gauze,  the  conjunctival  sac  made  aseptic,  and  the  lids  stitched 
together. 

The  Operation. — For  convenience  of  description  the  operation  is  divided 
into  six  stages : 

The  First  Stage  (incision  through  the  skin  and  reflection  of  the  flap). — 
A  semicircular  flap  is  made  extending  from  about  half  an  inch  below  the 
external  angular  process  of  the  frontal  bone  backward  along  the  upper  bor- 
der of  the  zygoma  its  entire  length.  From  this  point  the  incision  is  con- 
tinued downward  over  the  parotid  region  of  the  jaw,  to  just  in  front  of  the 
angle  of  the  jaw,  then  forward  along  the  lower  border  of  the  horizontal 
ramus  to  the  facial  vessels  (Fig.  318,  A).  This  flap  is  raised,  carried  for- 
ward, and  fastened  by  a  temporary  suture  to  the  upper  part  of  the  chin, 
and  securely  covered  with  protective  gauze. 

The  Second  Stage  (section  of  the  zygoma  and  coronoid  process,  displace- 
ment of  masseter  and  temporal  muscles). — The  zygoma  is  cut  down  upon 
at  either  extremity  and  bared  by  a  periosteotome  or  raspatory.  Two  holes 
fitted  to  carry  a  silver  wire  of  a  twenty-two-inch  gauge  are  drilled  one 
third  of  an  inch  apart  through  the  zygoma  at  the  points  of  exposure 
— i.  e.,  at  the  base  of  the  projection  and  at  the  zygomatic  process  of  the 
malar  bone.  The  bone  is  then  divided  between  the  holes  with  a  fine  saw, 
the  anterior  section  being  directed  obliquely  downward  and  forward,  the 
posterior  more  transversely,  and  as  near  to  the  root  of  the  process  as  possi- 
ble. The  fragment  of  bone  is  now  displaced  carefully  downward  along  with 
the  masseter  as  far  as  practicable;  the  coronoid  process  and  the  tendon  of 
the  temporal  muscle  are  easily  and  promptly  exposed  by  the  displacement 
and  removal  of  a  small  amount  of  intervening  cellular  tissue ;  the  coronoid 
process  and  a  portion  of  the  attached  muscle  are  removed  by  the  aid  of  bone 
forceps,  scissors,  or  the  Gigli-Haertel  saw,  etc. 

The  Third  Stage  (search  for  the  foramen  ovale). — Displace  the  pterygoid 
fat,  locate  the  internal  maxillary  artery  as  it  passes  between  the  heads  of  the 


296 


OPERATIVE  SURGERY. 


external  pterygoid  muscle^,  tie  it  with  two  ligatures  and  divide  the  vessel  be- 
tween them.  Detach  the  external  pterygoid  muscle  from  the  great  wing  of 
the  sphenoid  and  the  pterygoid  plate  with  a  periosteotome,  and  push  it 
downward.  The  base  of  the  posterior  border  of  the  outer  pterygoid  plate  is 
carefully  located  with  the  finger,  and  at  a  distance  posteriorly  of  sixteen  (in 
female)  to  eighteen  (in  male)  millimetres  is  found  the  foramen  with  the 
nerve  escaping  through  it. 

The  Fourth  Stage  (entering  the  base  of  the  skull). — In  order  to  effect 
this  purpose,  a  half-inch  trephine  is  applied  a  little  anterior  and  external 

to  the  foramen,  and  in  such  a  manner 
that  the  groove  made  in  the  bone  will  im- 
pinge on  the  outer  wall  of  the  foramen 
(Fig.  316).  This  opening  can  be  en- 
larged subsequently  in  any  direction  by 
the  use  of  bone  forceps  and  chisels. 

The  Fifth  Stage  (division  of  the 
nerves  and  removal  of  the  ganglion). — 
After  making  the  opening  in  the  bone, 
the  trunk  of  the  nerve  serves  as  a  guide 
to  the  ganglion.  The  ganglion  is  re- 
moved with  forceps  or  a  small  curette 
directed  along  the  course  of  the  nerve 
leading  to  it.  The  nerve  is  a  better 
guide  when  cut  as  far  back  as  possible, 
and  traction  be  made  on  the  stump.  The 
traction  draws  the  ganglion  forward  some- 
what, and  thus  facilitates  the  efforts  at 
destruction.  The  posterior  part  of  the  ganglion  can  be  displaced  more  read- 
ily and  removed  than  can  the  anterior  and  upper  part,  as  the  latter  is 
closely  connected  with  the  dural  sheath  of  the  nerve.  The  second  division 
is  found  and  divided  either  before  or  during  the  removal  of  the  ganglion 
(usually  during)  as  best  meets  the  indications  for  the  accomplishment  of 
that  act.    The  ophthalmic  division  is  not  disturbed. 

The  Sixth  Stage  (replacement  of  structures  and  closure  of  the  wound). 
— The  zygoma  is  replaced  and  wired  in  position,  and  the  skin  flaps  are  prop- 
erly approximated  and  sutured.  If  asepsis  has  been  complete,  no  drain- 
age is  necessary.  Continuous  pressure  with  sponges  or  properly  arranged 
pads  for  two  or  three  days  will  cause  suitable  apposition  for  prompt  union. 
The  eyes  should  be  protected  from  light  by  unirritating  aseptic  pads  fast- 
ened lightly  in  position. 

The  Hartley-Krause  Method. — The  Hartley-Krause  method  can  be  di- 
vided into  five  stages,  but,  unlike  the  Eose  method,  it  offers  better  opportu- 
nity for  manipulation  and  aseptic  technique,  and,  therefore,  is  followed  by 
better  results  than  the  latter  (Fig.  318). 

The  First  Stage  (forming  and  raising  the  flap). — After  thorough  dis- 
iiifection  of  the  ear,  scalp,  etc.,  a  horseshoe-shaped  incision  is  made  down  to 
the  bone  in  the  course  of  a  line  drawn  from  just  behind  the  external  angular 


Fig.  316. — Trephining  base  of  skull. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


29Y 


process  of  the  frontal  bone  upward  with  an  anterior  convexity  to  the  supra- 
temporal  ridge,  then  backward  and  downward  with  a  posterior  convexity  to 
just  in  front  of  the  tragus  of  the  ear  (Fig.  318;  B,  Hartley;  C,  Krause). 
The  base  of  the  flap  in  this  instance  corresponds  to  the  zygoma,  and  lies 


/ 


«! 

p  1 

, 

1 

/ 

1 

1 

.  If 

1 

1 

mlk\\ 

i 

1 

o  o  ^ 

/ 

1 

/f              / 

Fig.  317. — Instruments  employed  in  intracranial  neurectomy. 

a.  Pyle's  chisel,  b,  c.  Hartley's  chisels,  d.  e.  Mallet  and  trephine.  /.  Gigli-Haertel  saw. 
g.  Flexible  spatula,  h.  Hartley's  brain  retractor.  ?.  j.  A  common  flexible  and  a 
hooked  retractor,    h,  I.  Forceps  to  twist  away  and  curette  to  scrape  (?)  away  the  ganglion. 


298  OPERATIVE  SURGERY. 

between  the  points  of  starting  and  termination  of  the  curved  incision.    The 
flap  thus  formed  is  three  inches  in  both  the  vertical  and  transverse  diam- 
.. — ^_  eters.      Arrest   the  haemor- 

rhage;  retract   the   borders 
of    the    incision    carefully; 
^   ^^  ^^         cut  a  groove  in  the  line  of 

periosteal  division  down  to 
Q  ~N^       j  jf|     the  inner  table  in  a  beveled 

manner  (Fig.  319)  at  all 
parts  except  at  the  upper 
border,  and  here  through 
both  tables  with  the  chisels 
Ai       W/y  ^af      of  Hartley  or  that  of  Pyle 

(Fig.  317,  a,  h,  c).  The 
flap  is  now  pried  off  by  in- 
serting beneath  the  bone  at 
the  completely  divided  bor- 
/  la  der  a  bone  elevator,  which 

act  causes  fracture  at  the 
basal  end  of  the  undivided 
vitreous  table.  Expose  the 
dura  by  turning  down  the 
Pig.  318. — Lines  of  incision  in  intracranial  f]^a,p    (Fiff.    320)     the   bony 

neurectomy.  ,.  ^       p      i  •  i    ■  ■, 

portion  01  which  is  securely 

held  by  a  hinge  composed  of  integument,  muscle,  and  periosteum. 

The  Second  Stage  (treatment  of  the  middle  meningeal  artery). — Haem- 
orrhage from  the  middle  meningeal  and  its  branches  often  happens,  and  is 


Pig.  319.— Making  the  bone  flap. 

frequently  very  troublesome.     If  the  anterior  branch  happens  to  run  in  a 
canal  instead  of  a  groove  at  the  base  of  the  flap,  it  will  be  almost  surely  torn 


OPERATIONS  ON   THE   NERVOUS  SYSTEM. 


299 


across  (Fig.  274).  In  separating  the  dura  from  the  hone  at  the  entrance  to 
the  fossa,  the  main  trunks  may  be  ruptured.  After  exposure  of  the  dura, 
the  vessel  should  be  isolated  and  tied  as  promptly  and  securely  as  possible. 
If  the  vessel  be  torn,  prompt  i)ressure  is  applied,  the  vessel  exposed  by  cut- 
ting away  the  bone  and  then  tied  with  silk.  If  the  main  trunk  be  rup- 
tured, and  can  not  be  otherwise  secured,  prompt  pressure,  followed  by  plug- 
ging of  the  foramen  spinosum  with  gauze  for  three  days,  will  permanently 
arrest  the  bleeding  (Keen). 

The  Third  Stage  (raising  temporo-sphenoidal  lobe). — Separate  the  dura 
from  the  bone  carefully  with  the  fingers ;  raise  the  brain  cautiously  with  a 
broad  spatula  from  the  middle  fossa  preparatory  to  exposure  of  the  Gasserian 
ganglion  and  the  second  and  third  divisions  of  the  nerve.  The  separation 
of  the  dura  is  attended  with  quite  free  hajmorrhage  in  nearly  every  case,  but 
in  most  instances  patiently  employed  sponge  pressure  will  arrest  it.  Fail- 
ing in  this  the  fossa  is  packed  with  iodoform  gauze  and  the  wound  closed  and 
dressed ;  the  gauze  is  removed  on  the  third  day  and  the  operation  completed. 


Fig.  320.— 1,  2,  3.  Branches  of  fifth  nerve.    4.  The  ganglion. 


Keen  advises  this  course,  and  has  practiced  the  introduction  freely  in  three 
separate  instances :  in  one,  a  strip  37  X  6  inches,  in  another  23  X  14  inches, 
in  a  third  16  X.  6  inches,  was  introduced,  and  "  in  each  instance  the  gauze 
remained  in  place  for  three  days  without  any  material  symptoms." 

The  Fourth  Stage  (recognition  and  removal  of  ganglion  and  nerves). — It 
is  very  important  at  this  time  that  a  good  light  be  at  hand  (Fig.  Ill), in  order 
to  enable  the  surgeon  to  act  in  an  exact  and  intelligent  manner.  The  carotid 
artery  and  the  cavernous  sinus  may  each  be  opened,  if  careless,  blind,  or  mis- 
directed attempts  be  practiced  in  removal  of  the  ganglion.  Keen  advises 
that  the  head  rest  on  the  occiput,  and  that  a  side  light  be  employed,  for  in 
this  position  the  blood  flows  away  from  the  ganglion  instead  of  obscuring  it, 
as  when  the  head  lies  on  the  side.  Arrest  the  hnemorrhagc  and  locate  the 
nerve  by  either  the  sense  of  sight  or  touch.    The  middle  meningeal  artery 


300  OPERATIVE  SURGERY. 

as  it  passes  through  the  foramen  spinosum  lies  from  one  fourth  to  one  half 
inch  outside  of  the  foramen  ovale  which  transmits  the  third  division,  and 
it  is  therefore  a  guide  to  this  division.  Lifting  the  dura  will  cause  two  lines 
of  tension  of  the  membrane,  which  will  lead  to  the  foramina  of  exit  of  the 
second  and  third  divisions  respectively.  Expose  and  separate  the  nerves  from 
the  dura ;  follow  the  nerves  backward  to  the  ganglion,  separating  the  mem- 
brane from  them,  and  then  from  the  ganglion  itself  by  blunt  dissection  and 
traction  of  the  membrane.  Isolate  the  ganglion  and  the  second  and  third 
divisions  on  all  sides ;  seize  the  part  of  the  ganglion  corresponding  to  second 
and  third  divisions  with  haemostatic  forceps,  divide  with  scissors  the  second 
and  third  divisions  at  the  foramina,  then  rotate  the  forceps  gently  and  firmly, 
thus  twisting  away  the  ganglion  and  the  divisions,  including  possibly  the 
motor  root. 

The  Fifth  Stage  (closure  of  the  wound). — After  complete  arrest  of  haem- 
orrhage and  the  introduction  of  drainage  when  required,  return  the  temporal 
flap  to  its  place  and  confine  it  there  by  sewing  the  borders  of  the  divided 
periosteum  and  scalp  independently  of  each  other  with  catgut.  Dress 
the  wound  aseptically,  put  the  patient  in  bed,  and  treat  indications  as  they 
arise. 

The  Precautions. — In  fashioning  the  skin  flap  in  Eose's  method  avoid 
going  so  deep  as  to  injure  the  branches  of  the  seventh  nerve  or  Stenson's  duct. 
As  the  tendon  of  the  temporal  muscle  is  attached  lower  on  the  inner  than  on 
the  outer  surface  of  the  coronoid  process,  more  difficulty  will  be  experienced 
in  its  division  at  the  former  situation.  The  possession  of  a  strong  electric 
light  and  reference  to  a  dry  skull  will  help  much,  indeed,  in  the  localization 
and  inspection  of  important  parts.  In  making  the  opening  with  the  tre- 
phine at  the  base  of  the  skull,  it  must  be  remembered  that  the  thickness 
of  the  bone  at  this  situation  is  unequal,  being  thinner  at  the  outer  than  at 
the  inner  margin  of  the  trephine  track.  And,  inasmuch  as  the  instrument 
must  be  applied  to  the  bone  obliquely,  the  division  of  the  outer  part  of  the 
circle  will  be  made  more  quickly.  If  these  facts  be  not  heeded  or  pro- 
portionate care  be  not  exercised,  the  dura  will  surely  be  lacerated  by  the 
instrument. 

The  Complications. — Haemorrhage  is  the  only  complication  of  special 
significance.  The  middle  and  small  meningeal  arteries  may  be  injured 
during  approach  to  the  ganglion,  and  the  cavernous  sinus,  during  its  removal. 
It  has  been  demonstrated  recently  (Taylor)  that  the  foramen  spinosum  is 
sufficiently  far  from  the  foramen  ovale  so  that  the  approach  to  the  latter  can 
be  safely  made  without  injury  to  the  middle  meningeal  artery  in  a  majority 
of  instances.  However,  in  some  cases  the  foramen  spinosum  is  so  nearly  in 
the  line  of  approach  to  the  foramen  ovale,  that  haemorrhage  from  the  mid- 
dle meningeal  is  avoided  only  by  finding,  ligaturing,  and  dividing  this  vessel 
in  advance  of  the  extended  procedure.  Brisk  haemorrhage  from  the  small 
meningeal  which  passes  through  the  foramen  ovale  is  to  be  expected.  If  the 
vessel  can  be  secured  in  advance,  well  and  good ;  if  not,  then  ligature  at  the 
time  of  the  bleeding  will  suffice.  Sometimes  free  haemorrhage  arises  at  the 
time  of  removal  of  the  ganglion,  due,  perhaps,  to  involvement  of  the  sinus. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  301 

For  this  reason,  great  pains  should  be  taken  to  limit  the  manipulations  to  the 
ganglion  alone,  as  a  deviation  therefrom  may  involve  a  contiguous  sinus.  If 
hgemorrhage  arise  from  this  source,  a  tamponade  of  iodoform  gauze  should 
be  applied  and  permitted  to  remain  until  the  bleeding  is  finally  arrested. 

The  Remarks. — The  right  side  is  affected  twice  as  often  as  the  left;  the 
third  division  alone,  ten  times ;  second,  six  times ;  all  divisions,  twenty-two 
times.  The  first  division  is  never  affected  singly  (Tiffany).  If  the  bony 
opening  be  too  small,  it  can  be  increased  with  a  rongeur  at  will.  Tiff'anv  in 
his  "  later  operations  "  has  omitted  replacement  of  the  bone  flap,  and  now 
sees  "  no  special  reason  for  so  doing — i.  e.,  replacing  it."  Evacuation  of 
the  cerebro-spinal  fluid  by  limited  incision  of  the  dura,  which  is  closed 
promptly  thereafter,  greatly  facilitates  the  raising  of  the  brain  from  the  floor 
of  the  skull.  An  unusual  depth  of  the  anterior  fossa  and  adhesion  of  the 
dura  increase  the  difficulty  of  the  operation.  The  first  division  of  the  fifth 
nerve  should  not  be  disturbed,  as  this  part  of  the  nerve  is  not  affected  singly. 
However,  the  second  and  third  divisions  and  the  corresponding  parts  of  the 
ganglion  should  be  completely  removed,  also  the  remaining  part  of  the  gan- 
glion if  practicable.  The  saving  of  the  motor  branch  of  the  third  division  is 
not  necessar}^  except  both  sides  be  subjected  to  the  operation,  when,  of 
course,  the  muscles  of  mastication  would  be  incapacitated.  Keen  regards  it 
scarcely  possible  to  save  this  branch. 

Many  surgeons  use  the  electro-motor  (Fig.  281)  and  Gigli-Haertel  saw 
(Fig.  317,  /,  i)  in  making  the  bone  flap,  since  the  concussion  incident  to 
the  use  of  chisel  and  mallet  is  thus  avoided.  These  saws,  along  with  a  small 
trephine,  placed  at  intervals,  serve  to  establish  the  size  and  shape  of  bone 
flaps,  which  can  be  made  nearly  square  or  otherwise  modified. 

The  Results. — Lexer  reports  two  hundred  and  one  cases  with  94.4  per 
cent  apparently  cured,  with  seventeen  per  cent  mortality.*  Keen  reports 
twenty-two  cases  with  four  deaths  from  Eose's  operation,  and  fifty-one 
cases  with  five  deaths  from  the  Hartley-Krause  method.  Tiffany  reports 
one  hundred  and  eight  cases  with  a  death  rate  of  twenty-two  and  a  fifth  per 
cent.  Shock  and  sepsis  each  caused  a  third  of  the  deaths.  The  recurrence  of 
pain  more  or  less  severe  after  presumptive  removal  of  the  nerves  happens  in 
four  or  five  per  cent  of  the  cases.  But  recurrence  of  pain  after  "  known 
removal  "  of  the  ganglion  is  not  5'et  recorded  (Tiffany). 

The  Sequels. — Corneal  ulceration  is  a  sequel  of  significance,  and  per- 
haps may  be  due  to  too  free  meddling  with  the  first  division  and  the  upper 
part  of  the  ganglion.    Some  atrophy  of  tongue  and  eye  follow  in  many  cases. 

Loss  of  sensation  of  the  face  and  meningitis  are  also  sequels  of  this  oper- 
ation. The  former  is  inevitable,  but  sensation  is  regained  in  an  astonishing 
manner.  The  danger  of  sloughing  of  the  eye  can  be  reduced  to  a  minimum 
by  exclusion  of  light  and  other  forms  of  irritation,  and  the  maintenance  of 
cleanliness  by  stitching  together  the  lids  at  the  center  and  washing  beneath 
them  from  time  to  time  with  a  warm  boric  acid  solution  for  four  or  five 
days,  followed  by  their  liberation  and  the  use  of  a  proper  shield  (Keen). 

*  Arch.  f.  klin.  Chir.,  Bd.  Ixv,  H.  4. 


302  OPERATIVE  SURGERY. 

The  division  with  the  nerves  of  the  tubular  meningeal  prolongations  that 
surround  them  exposes  the  meningeal  space  to  danger  of  infection.  Still, 
if  the  wound  be  aseptic,  little  fear  of  this  complication  need  be  entertained. 

Doyen's  Method. — Doyen's  method  seems  to  offer  proper  access  to  the 
ganglion  with  less  injury  of  the  brain,  and  perhaps  better  observation  than 
the  preceding  methods.  However,  the  trials  necessary  to  establish  its  worth 
are  lacking.  The  following  excellent  description  of  the  procedure  is  quoted 
from  the  Annals  of  Surgery,  January,  1896 : 

"  1.  A  sickle-shaped  incision  is  made  through  the  soft  parts  over  the 
temporal  region  (Fig.  315,  c).  The  vertical  portion,  corresponding  to  the 
handle  of  the  sickle,  is  from  five  to  six  centimetres  long  and  is  made  in 
the  space  between  the  external  auditory  meatus  and  the  outer  angle  of 
the  orbit.  This  incision  should  pass  not  more  than  fifteen  millimetres  be- 
low the  zygomatic  arch,  and  should  avoid  as  far  as  possible  the  branches 
of  the  facial  artery  and  nerve. 

"  2.  Eesection  of  the  zygomatic  arch  close  to  the  condyle,  division  of  the 
coronoid  process,  and  denudation  of  the  temporal  fossa. 

"  3.  Identification  of  the  inferior  dental  nerve, which  divides  two  or  three 
centimetres  lower  down ;  identification  of  the  lingual  nerve.  Both  are  then 
divided  and  the  cut  ends  held  by  toothed  forceps.  The  internal  maxillary 
artery  is  ligated  close  to  the  point  of  origin. 

"  As  soon  as  the  isolation  of  the  trunk  of  the  inferior  maxillary  division 
as  far  as  its  point  of  exit  from  the  foramen  is  assured,  the  skull  is  opened 
by  a  trephine  or  other  suitable  means  at  the  level  of  the  spheno-temporal 
suture.  By  means  of  suitable  cutting  forceps  the  greater  wing  of  the 
sphenoid  and  the  squamous  portion  of  the  temporal  bones  are  removed  bit 
by  bit  over  the  entire  area  of  the  lower  portion  of  the  temporal  fossa  ex- 
posed by  the  previous  resection  of  the  zygomatic  arch. 

"  As  soon  as  the  antero-posterior  ridge  formed  by  the  union  of  the  verti- 
cal portion  of  the  greater  wing  of  the  sphenoid  with  its  base  is  reached, 
the  basal  part  is  attacked,  and  progressively  removed  as  far  as  the  foramen 
ovale.  The  external  semicircumference  of  this  is  removed  by  the  final  cut 
of  the  forceps.  The  area  of  bone  removed  in  the  course  of  the  operation  is 
shown  in  Figs.  321  and  324. 

"  The  forceps  are  still  attached  to  the  inferior  dental  and  lingual  nerves, 
and  with  their  aid  the  trunk  of  the  inferior  maxillary  is  raised,  and  the  in- 
tradural pocket  in  which  the  ganglion  lies  is  opened  from  the  outer  side. 
Traction  can  then  be  made  upon  the  ganglion  itself,  and  with  a  little  care 
its  anterior  and  posterior  aspects  are  exposed  and  freed  from  attachments. 
The  superior  maxillary  division  is  made  free  in  like  manner  as  far  as  the 
foramen  rotundum  where  it  is  divided;  finally,  the  ophthalmic  division  is 
cut  at  the  sphenoidal  fissure. 

"  When,  as  was  the  case  in  the  first  patient  upon  whom  Doyen  operated, 
the  superior  maxillary  division  has  previously  been  severed  beneath  the 
orbit,  a  little  tension  and  manipulation  will  usually  suffice  to  remove  the 
remainder  of  the  nerve. 

"  The  ophthalmic  division  is  divided  at  its  entrance  into  the  sphenoidal 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  303 

fissure.  By  the  aid  of  a  small  elevator  the  entire  periphery  of  the  ganglion 
is  completely  freed,  and  made  movable  by  traction  upon  its  efferent  nerves, 
which  renders  it  possible  to  expose  the  superior  border  of  the  petrous  portion 
of  the  temporal  bone  and  the  dural  canal  which  serves  as  a  sheath  for  the 
primary  trunk  of  the  trigeminus  beneath  the  superior  petrosal  sinus.    This 


Fig.  321. — Outline  of  bone  removed  at  side  of  skull. 

last  nerve  trunk  is  isolated  in  its  turn,  and  then  divided  instead  of  the 
ganglion  upon  the  posterior  aspect  of  the  petrous  bone  beneath  the  venous 
sinus. 

"  The  carotid  artery  is  seen  at  the  bottom  of  the  wound  protected  ])y  a 
thin,  fibrous  sheath.  It  is  easy  to  avoid  wounding  the  cavernous  sinus,  pro- 
vided the  operator  be  careful  and  skillful." 

Cushing's  Method.* — Gushing  by  this  method  avoids  the  middle  menin- 
geal artery  while  approaching  the  ganglion  through  a  comparatively 
straight  route,  thus  limiting  the  danger  from  haemorrhage  and  from  manip- 
ulation of  the  brain — i.  e.,  securing  a  maximum  exposure  with  a  mini- 
mum danger  from  cerebral  involvement  and  haemorrhage. 

The  Operation. — Make  a  horseshoe-shaped  flap,  with  the  base  at  the 
zygoma,  about  -1  centimeters  (1^  inch)  wide  and  5  centimeters  (3  inches) 
high;  turn  downward  the  skin  flap  to  just  below  the  zygoma,  tying  the  tem- 
poral vessels  and  exposing  the  corresponding  temporal  fascia  down  to  the 
zygoma ;  make  through  the  temporal  fascia  an  incision  concentric  witli  and 
just  within  the  border  of  the  skin  incision,  down  to  the  middle  of  the  outer 
surface  of  the  zygoma,  then  along  this  surface,  through  the  periosteum  to 
the  opposite  border  of  the  flap ;  separate  from  the  zygoma  the  periosteum, 
except  at  the  attachment  of  the  masseter  muscle,  and  sever  the  bony  arch 
at  the  anterior  and  posterior  extremities  with  saw  or  forceps :  make  an  in- 
cision through  the  temporal  muscle  down  to  the  bone,  concentric  with  the 
preceding  one ;  raise  the  divided  muscle  and  turn  it  firmly  downward  along 
with  the  fascia  and  resected  part  of  the  zygoma,  thus  exposing  down  to  the 

*  Jour.  Amer.  Med.  Ass'n,  April  18.  1900. 


304 


OPERATIVE  SURGERY. 


zygomatic  ridge  (infra-temporal  crest)  the  lower  portion  of  the  temporal 
fossa;  make  an  opening  about  3  centimeters  (1|  inch)  in  diameter — lim- 
ited below  and  perhaps  involving  the  zygomatic  crest — through  the  most 
prominent  portion  of  the  wing  of  the  sphenoid  down  upon  the  dura  with 
trephine^  mallet  and  gouge,  and  rongeur,  thus  revealing  the  dura  and  the 
meningeal  artery  as  it  crosses  the  opening ;  expose  the  upper  surface  of  the 
ganglion  and  its  branches,  especially  (Fig.  323)  the  sensory  root  by,  1,  rais- 


/    <-'*' 


'^,mr- 


Fig.  322. — Intracranial  neurectomy,  Cushing's  method.    The  exposure  of  the  ganglion. 

ing  from  the  base  of  the  middle  fossa  the  dura,  back  to  the  foramen  ovale 
by,  3,  careful  blunt  dissection  of  the  dura  from  about  the  oval  and  round 
foramina  and  the  space  between  by,  3,  splitting  the  edge  of  the  dural  envel- 
ope encasing  the  ganglion  and  its  peripheral  branches,  raising  up  the  supe- 
rior covering  of  these  structures,  permitting  them  to  remain  undisturbed  on 
the  underlying  part  of  the  envelope;  liberate  the  ganglion,  its  anterior 
branches  and  its  sensory  root  from  the  underlying  connections  by,  1,  liberat- 
ing by  blunt  dissection  the  second  and  third  branches  and  the  ganglion 
by,  2,  freeing  the  superior  (Fig.  323)  and  internal  borders  of  the  sensory 
root  and  the  first  anterior  branch  by  similar  means  by,  3,  grasping  with 
hgemostatic  forceps  the  ganglion  at  the  trigeminal  root,  followed  by  cutting 
with  scissors  the  peripheral  branches  just  before  their  escape  from  the-  skull, 
finally  the  evulsion  of  the  sensory  root  with  the  attached  forceps  and  the 
removal  of  the  entire  mass. 

After  arrest  of  haemorrhage  and  thorough  cleansing  of  the  wound 
restore  the  superficial  tissues  to  their  respective  places,  stitching  each  in  turn 
to  corresponding  structures,  including  the  zygoma,  cover  the  eye  with  rub- 
ber protective,  dress  the  wound  in  the  usual  manner,  carefully  avoiding 
pressure  upon  the  eye. 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


305 


The  Bemarhs. — It  is  very  important  to  heed  the  fact  that  the  opening 
into  the  skull  is  sufficiently  low  to  permit  of  the  elevation  of  the  dura 
and  of  approach  to  the  ganglion  beneath,  the  meningeal  artery,  thus  avoid- 
ing the  danger  of  haemorrhage  so  often  attendant  on  the  approach  from 
above.  Paralysis  of  the  corresponding  occipito-frontalis  muscle  is  a  com- 
mon sequel.  The  firm  attachment  of  the  masseter  suggests  the  preserva- 
tion rather  than  the  removal  of  the  resected  zygoma.  The  small  size  of  the 
opening,  its  comparatively  obscure  and  protected  situation,  renders  a  bony 
flap  of  no  special  benefit.  The  bone  at  the  upper  part  of  the  area  of 
approach  is  thin  and  should  be  attacked  with  caution,  to  avoid  injury,  espe- 
cially of  the  meningeal  artery,  which  passes  immediately  beneath.  The 
thickest  portion  is  below,  and  can  be  removed  with  the  rongeur.  Fragments 
of  bone  should  be  carefully  excluded  from  the  wound,  as  they  may  cause 
much  trouble.  The  ganglion  should  not  be  liberated  until  after  the  superior 
covering  is  raised  and  the  branches  are  exposed  and  liberated,  thus  post- 
poning the  bleeding  that  so  often  attends  the  elevation  of  the  ganglion,  also 
facilitating  the  uncovering  of  the  ganglion  and  the  elevation  itself.  The  lib- 


FiG.  323. — Intracranial  neurectomy,  Cushing's  method.    The  liberating  of  the  ganglion. 

a.  The  middle  meningeal  arteiy.  b.  The  size  of  operative  opening,  c.  The  abducens 
nerve,  d.  The  opening  in  skull,  e.  The  middle  meningeal  artery.  /.  The  semi- 
lunar ganglion,    g.  The  reflected  dura.     h.  The  dura  propria  of  ganglion. 


eration  and  extraction  of  the  ganglion  and  its  connections  are  difficult,  and 
are  greatly  facilitated  by  preliminary  training  on  the  dead  body.  Only  expe- 
rience can  practically  adjust  the  degree  of  force  needed  to  safely  accom- 
plish the  purpose.     Manipulation  at  the  foramen  ovale,  injury  of  the  cav- 


306  OPERATIVE  SURGERY. 

ernous  sinus  in  freeing  the  first  division  and  the  ganglion,  and  injury  from 
attendant  mishaps,  each  causes  a  haemorrhage  more  or  less  severe,  but  which 
usually  yields  to  gauze  pressure  of  a  few  moments'  duration.  The  sixth 
nerve  is  frequently  injured  in  isolating  the  ophthalmic  division,  and  the 
sympathetic  always  because  of  its  direct  and  indirect  connection  with  the 
ganglion  itself.    However,  the  effects  of  these  injuries  may  soon  subside. 

The  Results. — The  following  communication  to  me  from  Dr.  Gushing, 
written  March  9,  1904,  explains  itself :  "  I  have  personally  had  twenty  cases, 
one  of  which  did  not  survive  the  operation ;  the  fatal  result,  however,  being 
explainable  on  grounds  other  than  the  craniotomy  itself.  The  operation 
should  be  conducted  between  the  two  fixed  points  of  the  meningeal,  which 
should  not  be  injured  either  at  the  foramen  spinosum  or  at  the  sulcus  arte- 
riosis.  In  addition  to  the  twenty  cases  of  my  own,  I  know  of  about  thirty 
more,  in  which  only  one  or  two  deaths  occurred.  The  method  applies,  of 
course,  only  to  the  approach.  The  treatment  of  the  ganglion  itself  is  or 
should  be  the  same  in  all  methods.  I  have  always  endeavored  to  remove 
the  ganglion  in  its  entirety  and  have  succeeded  in  about  80  per  cent,  of 
the  cases." 

Abbe's  Method.* — Make  a  vertical  incision  through  the  soft  parts  of  the 
temporal  region  down  to  the  bone  upon  the  middle  of  the  zygoma ;  draw  the 
borders  of  the  wound  apart  by  retractors,  exposing  the  sphenoid  bone ;  make 
an  opening  an  inch  and  a  half  in  diameter  through  the  bone,  disclosing  the 
dura;  raise  the  dura  from  the  middle  fossa,  revealing  the  second  and  third 
divisions  of  the  nerve;  grasp  each  nerve  trunk  with  an  artery  clamp  close 
to  its  foramen  of  exit  and  divide  it  with  scissors;  cut  off  with  scissors,  or 
avulse  the  branches  from  the  ganglion  by  means  of  the  forceps  already 
closed  in  place;  arrest  haemorrhage  by  packing,  and  then  place  over  the 
foramina  of  exit  of  these  nerves  a  sterilized  piece  of  gutta-percha  tissue 
an  inch  and  a  half  long  and  three  fourths  of  an  inch  wide ;  press  carefully 
into  place  this  tissue  with  iodoform  gauze,  leaving  the  gauze  in  place  for 
a  few  moments,  then  withdraw  it,  permitting  the  ganglion  to  rest  upon  the 
gutta-percha  tissue;  close  the  wound  by  deep  stitches  in  the  usual  manner, 
providing  drainage  for  a  short  time  to  secure  dry  healing. 

The  Remarhs. — Abbe  reports  several  cases  of  his  own  showing  excellent 
primary  results,  all  of  which  are  cured,  the  extremes  being  six  years  and 
six  months  respectively.  If  this  method  of  practice  should  prove  equally 
as  efficient  as  those  of  greater  severity,  then,  indeed,  will  much  have  been 
accomplished.  However,  since  there  are  reasons  inviting  doubt  in  this 
regard,  further  experience  is  quite  essential  for  final  determination. 

The  Spiller  and  Frazer  Method,  f — This  method  essentially  consists  in 
substituting  division  of  the  sensory  root  of  the  ganglion  for  other  methods 
of  practice.  Should  the  outcome  show  that  failure  of  regeneration  of  the 
divided  or  resected  nerve  prevents  the  return  of  the  affliction,  then,  indeed, 
will  the  technique  be  simplified  and  the  dangers  and  sequels  correspond- 

*  Annals  of  Surg.,  Jan.,  1903. 

f  University  of  Pennsylvania  Med.  Bull.,  Dec,  1901. 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


307 


ingly  lessened.    The  technique  of  approach  to  the  special  operation  field  in 
this  instance  need  not  essentially  differ  from  others  already  dcscrihed. 

Horsley's  Intradural  Operation  of  division  of  the  nerve  at  the  hase  of 
the  skull  through  an  opening  into  the  middle  fossa  made  in  the  temporal 
region  is  a  bold  conception,  which,  however,  appears  to  be  needlessly  dan- 
gerous for  the  purpose  and  even  unnecessary,  in  view  of  the  results  and  the 
increased  thoroughness  of  removal  by  the  extradural  methods. 

The  Facial  Nerve.— The  facial  nerve  is  exposed  for  the  purpose  of 
stretching  to  arrest  spasm  of  the  muscles  supplied  by  it,  and  also  it  is  bared 
not  infrequently  in  some  part  of  its  course  at  the  outset  of  an  operation 
contiguous  to  the  nerve,  to  avoid  the  effects  of  unnecessary  injury  of  the 
trunk  or  the  larger  branches  at 
that  time.  The  'bony  guides  to 
the  nerve  are  the  mastoid  pro- 
cess, the  zygoma,  and  the  angle 
of  the  lower  jaw.  The  insertions 
of  the  sterno-mastoid,  the  digas- 
tric, and  the  prevertebral  mus- 
cles can  be  classed  as  the  muscu- 
lar guides.  A  point  about  mid- 
way between  the  angle  of  the  jaw 
and  the  zygomatic  arch  indicates 
the  situation  of  the  nerve  as  it 
passes  forward  from  the  foramen 
of  exit.  The  nerve  can  be  ex- 
posed through  an  incision  made 
behind  (Baum)  (Fig.  314)  or  in 
front  (Hueter)  of  the  pinna.  The 
former  method  is  the  better  one. 

Baum's  Operation. — Begin  the 
primary  incision  just  behind  the 
pinna  and  on  a  level  with  the 
external  auditory  meatus,  carry  it 
downward  and  forward  to  nearly 
the  angle  of  the  jaw,  passing  im- 
mediately below  the  lobule,  and 
curve  it  upward  slightly  at  this 
point.  Divide  the  superficial  and 
parotid  fascife;  expose  the  pos- 
terior border  of  the  parotid  gland  and  the  anterior  border  of  the  tendinous 
fibers  of  insertion  of  the  sterno-mastoid  muscle,  and  draw  these  structures 
apart  with  hooks.  Expose  carefully  the  anterior  border  of  the  mastoid 
process,  and  at  a  point  about  one  third  of  an  inch  in  front  of  the  center  of 
this  border  the  nerve  is  found  at  a  point  about  half  an  inch  from  the  fora- 
men of  exit.  The  origin  of  the  digastric  muscle  is  seen  close  at  hand,  pos- 
teriorly. The  nerve  is  then  caught  up  and  stretched  by  means  of  a  blunt 
hook  with  a  force  equal  in  weight  to  five  or  six  pounds. 


Fig. 


824. — Outline  of  bone  removed  at  base 
of  the  skull. 


308 


OPERATIVE  SURGERY. 


The  Comments. — The  operation  is  easy  in  those  of  spare  development,  but 
in  fleshy  and  muscular  subjects  it  is  often  accomplished  only  with  consider- 
able difficulty.  After  the  exposure  and  clearing  of  the  space  between  the 
gland  and  the  insertion  of  the  sterno-mastoid,  the  employment  of  electricity 


Fig.  325. — ^.The  repair  of  facial  nerve  by  means  of  spinal  accessory  nerve. 


OPERATIONS  ON   Tllp]   NERVOUS  SYSTKM. 


309 


IfC'TJ^^-IJ 


Fig.  326. — Instruments  employed  in  laminectomy. 

a,  I.  Scalpels,    c,  d,  e,  f.  Retractors,    g.  Rongeur.     /(.  Gigli-IIaertel  saw.    t.  Bone  ele- 
vator,   y.  Periosteotome.     k.  Sequestrum  forceps.     I.  Keen's  bone-gnawing  forceps. 
711.  Liston's  bone-cutting  forceps.     Forcipressure  and  ligatures  in  abundance,  drain- 
age agents,  etc.,  are  needed. 
23 


310  OPERATIVE  SURGERY. 

by  means  of  a  wet  sponge  to  the  face  and  a  fine  wire  electrode  in  the  course 
of  the  nerve  will  promptly  demonstrate  the  situation  of  the  nerve,  and  thus 
avoid  unnecessary  delay  and  injury  of  the  tissues  (Keen).  The  irritating  of 
the  nerve  in  the  wound  with  a  probe  will  likewise  cause  diagnostic  mani- 
festations of  its  presence  there.  If  the  nerve  be  seized  too  far  down,  the 
fibers  of  the  posterior  auricular  and  styloid  branches  will  escape  the  full 
effect  of  the  stretching,  therefore  the  trunk  should  be  followed  upward  and 
stretched  at  a  point  above  the  origin  of  these  branches.  A  strong  light, 
good  retractors,  and  vigorous  sponging  greatly  facilitate  the  securing  of 
the  nerve. 

The  Results.- — Temporary  relief  is  secured  promptly;  but  since  the  func- 
tion of  the  nerve  is  restored  in  from  a  few  days  (seven)  to  twelve  months 
in  the  majority  of  cases,  a  satisfactory  cure  can  not  be  promised.  However, 
as  a  number  of  cases  have  been  relieved  for  a  year  or  more,  the  outlook  can 
be  regarded  as  justifying  further  attempts  in  this  direction. 

Facial  Paralysis,  Extra-cerebral  Origin,  Operation  for  (Gushing).* — 
In  this  operation  the  facial  is  repaired  at  the  expense  of  the  spinal  accessory 
in  the  following  manner:  Expose  each  nerve  by  the  methods  already  de- 
scribed (pages  307,  319)  a  sufficient  length  to  permit  of  unrestrained  con- 
tact of  the  divided  extremities;  omit  dividing  either  nerve  until  both  are 
suitably  prepared  for  final  transfer  and  union ;  pass  a  delicate  silk  traction 
suture  through  the  perineural  sheath  of  the  selected  portion  of  each  nerve, 
close  to  the  point  of  proposed  division;  sever  in  turn  and  carefully  raise, 
aided  by  the  traction  sutures,  each  nerve  for  the  requisite  length  from  their 
respective  beds,  preserving  their  perineural  connective  tissue ;  unite  without 
tension  the  apposed  ends  of  the  divided  nerves  at  those  points  by  means 
of  curved  intestinal  needles  armed  with  delicate  threads  of  split  silk  (Fig. 
325) ;  arrest  all  oozing,  unite  the  borders  of  the  wounds  carefully  and  apply 
moderate  pressure  to  the  surface;  dress  and  care  for  the  wounds  with  the 
greatest  degree  of  caution. 

The  delicacy  of  this  operation  in  all  essential  details  is  of  such  an  im- 
portant character  as  to  preempt  a  full  and  unstinted  outlay  of  the  precau- 
tionary minutiffi.  The  great  aim  to  be  achieved  and  the  gloom  of  disappoint- 
ment that  would  attend  defeat  in  such  cases  as  these  is  a  matter  of  prime 
significance.  The  presence  of  infection  in  the  wound  or  the  employment 
of  a  too  vigorous  or  thoughtless  technic. might  easily  result  in  defeating  the 
purpose,  leaving  the  parts  involved  less  suited  for  surgical  effort  than 
before  the  attempt.  In  instances  of  successful  union  of  the  transferred 
parts  the  function  of  the  impaired  nerve  is  restored  gradually  and  only 
after  considerable  time.  Stimulating  the  transferred  nerve  causes  gro- 
tesque and  unmeaning  facial  movements,  which,  although  active  at  first, 
progressively  diminish  and  finally  cease  entirely,  or  at  least  are  a  source  of 
no  annoyance.  These  facts  suggest  that  the  nerve  selected  for  the  purpose 
of  repairing  of  function  be  one  where  normal  combined  function  may  be 
depleted  without  signal  loss  of  power  of  the  part  supplied,  also  where  trans- 
ferred influence  will  cause  a  minimum  degree  of  disfigurement  of  facial 

*  Annals  of  Surgery,  May,  1903. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  311 

expression.     It  seems  to  us  wise  that  tlio  patient  or  the  friends  be  made 
aware  of  the  effect  of  the  operation  at  the  outset. 

Tlie  RcmarlvS. — Other  contiguous  motor  nerves  may  be  utilized  for  the 
purpose,  as  the  hypoglossal  (Frazer*)  and  spinal.  The  accessory  nerve 
enters  the  mastoid  muscle  about  two  inches  below  the  tip  of  the  mastoid 
process.  The  division  of  the  nerve  at  the  point  of  entering  the  muscle 
should  afford  sufficient  of  its  structure  for  transplantation.  The  usual 
muscular  changes  incident  to  division  of  the  accessory  nerve  follow  here, 
but  are  of  minor  importance  compared  to  the  infliction  of  the  face  calling 
for  remedy.  Some  time  is  required  for  the  abatement  of  the  associated 
movements  incident  to  stimulation  of  the  transferred  nerve. 

OPERATIONS    ON   THE    SPINAL   CORD    AND    SPINAL   NERVES. 

Inasmuch  as  approach  to  the  spinal  cord  for  the  removal  of  agents  or 
conditions  that  impair  or  annul  its  functions  requires  the  displacement  or 
removal  of  superimposed  tissues  at  the  seat  of  involvement,  and  since  the 
character  of  these  tissues  is  substantially  similar  throughout  the  entire  course 
of  the  cord,  the  explorative  operative  procedure  differs  in  no  essential  re- 
spect at  the  various  parts  of  the  spine. 

Laminectomy. — The  operation  of  laminectomy  is  one  of  comparatively 
modern  birth,  and  as  yet  of  a  limited  application.  It  is  employed  to  relieve 
the  spinal  cord  of  otherwise  irremediable  pressure.  The  dangers  of  the  opera- 
tion are  pronounced,  and  all  available  measures  should  be  employed  to  fore- 
stall and  counteract  their  occurrence.  Sepsis,  haemorrhage,  shock,  and  im- 
paired respiratory  force  are  each  of  decided  significance,  and  if  perchance 
they  be  combined  in  an  individual  case,  the  outcome  is  scarcely  a  matter  of 
conjecture.  While  these  dangers  are  not  enumerated  here  in  the  order  of 
probable  occurrence,  still  the  enumeration  is  one  of  logical  sequence  in  the 
forethought  of  prevention. 

Sepsis. ~Thovo\\g\\  antiseptic  preparation  of  the  patient  and  of  the  de- 
tails of  the  procedure  will  prevent  infection,  if  it  has  not  already  happened 
as  the  result  of  the  injury,  or  has  been  invited  by  the  oversights  and  acci-- 
dents  of  subsequent  treatment.  Considerate  treatment  of  the  tissues  during 
the  operation,  and  intelligent  drainage  and  dressing  subsequent  to  the  act, 
are  very  important  factors  in  this  respect. 

Hmnorrhage.— The  haemorrhage  is  free  and  often  persistent,  on  account 
of  the  size  and  great  number  of  the  vessels  involved  in  the  procedure. 
However,  the  prompt  use  of  forceps  and  the  liberal  employment  of  hot  water 
and  sponge  pressure  robs  this  danger  of  grave  significance. 

SJwck.—The  mutilation  of  the  parts  and  the  loss  of  blood  attendant  on 
the  operation,  combined  with  the  mental  and  physical  depression  resulting 
from  the  original  injury,  should  not  be  underestimated  or  considered 
lightly.  When  circumstances  will  permit,  the  patient  should  be  prepared 
for  the  operation  with  due  consideration  to  mental  and  physical  complaisance, 
and  the  need  of  heart  tonics.  Physical  warmth  as  provided  by  an  abundance 
of  hot-water  bottles  and  woolen  blankets  should  be  employed.     All  unneces- 


*  Progressive  Medicine,  March  1,  1904. 


312  OPERATIVE  SURGERY. 

sary  exposure  of  the  body  or  limbs  should  be  avoided  with  sedulous  care 
during  operation. 

Impairment  of  Respiratory  Force. — The  impairment  of  the  auxiliary 
forces  of  respiration  dependent  on  interference  of  the  functions  of  the  spinal 
cord,  together  with  the  impediment  to  breathing  incident  to  necessary  ab- 
dominal decubitus  of  the  patient,  incite  not  infrequently  troublesome  and 
even  dangerous  respiratory  manifestations.  Therefore  the  patient  should  be 
so  placed  and  supported  as  to  interfere  as  little  as  possible  with  the  respira- 
tory forces,  the  head  being  placed  over  the  end  of  the  table  to  meet  the  re- 
quirements of  the  anaesthetist. 

The  Operation  of  Laminectomy. — Make  an  incision  in  the  median  line 
four  or  more  inches  in  length  down  upon  the  apices  of  the  spinous  processes 
of  the  vertebrae,  the  center  of  the  incision  corresponding  to  the  seat  of  the 
disease  or  injury.  Separate  the  tissues  at  one  side  from  the  spinous  pro- 
cesses and  laminae  of  the  vertebrae  by  carefully  directed  incisions  made  with 
a  knife,  drawing  the  structures  aside  with  broad,  thin  retractors  as  soon  as 
severed  from  their  connections,  thus  exposing  completely  the  posterior  bony 
wall  of  the  spinal  canal.  Arrest  haemorrhage  by  forcipressure  and  packing 
with  sponges  saturated  with  hot  water,  withdraw  the  retractors,  and  allow 
the  tissues  to  return  toward  the  median  line.  Having  treated  the  opposite 
side  in  a  similar  manner,  again  expose  the  primary  wound  to  the  fullest  ex- 
tent, and  with  a  raspatory  scrape  off  and  remove  the  muscular  tissue  remain- 
ing attached  to  the  bones.  Repack  the  wound,  and  repeat  this  procedure 
upon  the  opposite  side  (Fig.  327).  Draw  aside  the  tissues  from  the  median 
line,  and  divide  the  supraspinous  and  infraspinous  ligaments  with  a  scalpel, 
carefully  avoiding  the  membranes  of  the  cord;  gnaw  away  successively  the 
spinous  process  and  lamina  of  one  or  more  vertebrae  with  the  rongeur  forceps 
or  remove  with  the  Gigli-Haertel  saw  sufficiently  to  admit  to  the  spinal 
canal  the  laminectomy  forceps,  with  which  the  laminae  are  divided,  and  when 
removed  the  contents  of  the  spinal  canal  are  exposed  to  view  (Fig.  328). 
A  sharp  haemorrhage  often  arises  from  the  superficial  plexus  of  veins  at 
this  time,  but  it  is  arrested  easily  by  sponge  pressure  and  hot  water.  Lying 
beneath  the  arches  of  the  vertebrae  and  upon  the  dura  there  is  a  consider- 
able amount  of  closely  woven  connective  tissue,  supporting  in  its  meshes  a 
troublesome  plexus  of  veins.  This  tissue  is  carefully  divided  in  the  median 
line  down  upon  the  dura,  bleeding  being  arrested  in  the  usual  manner,  as  it 
occurs. 

The  Examination  of  the  Contents  of  the  Canal. — A  posterior  concavity  of 
the  spine  should  be  established  by  a  pad  placed  at  either  extremity  of  the 
trunk  (Chipault)  before  examination  is  commenced.  A  bluish  dura  indi- 
cates the  presence  of  blood,  and  a  yellowish  of  pus  beneath  it;  increased 
tension  and  firmness  denote  tumor ;  absence  of  pulsation  indicates  interfer- 
ence with  the  subdural  space  by  adhesions,  pressure,  etc.  After  exposure  of 
the  contents  of  the  spinal  canal,  and  before  opening  the  dura,  a  careful  scru- 
tiny of  the  bony  outline  of  the  canal  should  be  made  at  the  various  aspects, 
to  detect  the  presence  of  any  encroachment  of  bone  or  diseased  products  in 
a  degree  that  causes  symptomatic  pressure  of  the  cord.     In  fracture  of  the 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


313 


spin{3  and  in  Pott's  disease  this  step  is  of  o1)vious  importance,  since  it  may 
be  possible  to  remedy  the  impingement  without  division  of  the  membranes. 
To  obviate  the  danger  of  infection  diseased  products  should  be  scraped 
away  with  a  small  spoon,  aided  by  a  gentle  stream  of  hot  sterilized  water. 
The  correction  of  the  bony  trespass  is  not  so  easily  made,  owing  to  the 
greater  necessity  of  drawing  the  contents  of  the  canal  upward,  out  of  the 
way  of  the  instrumental  manipulations  necessary  for  the  removal  of  the  pro- 
jecting bone.  To  meet  this  indication  properly,  it  may  be  necessary  to  sever 
the  roots  of  one  or  more  of  the  spinal  nerves  at  one  side  of  the  canal.  The 
offending  bone  structure  is  cut  off  at  a  proper  line  (Fig.  329)  with  sharp- 


FiG.  327. — Exposure  of  posterior  structures 
of  spinal  column. 


Fig.  328. — Spinal  cord  exposed. 


curved  chisels,  or  dug  away  with  suitable  scoops.  After  proper  alignment  of 
the  bony  surface  and  thorough  cleansing  of  the  parts,  the  divided  roots  of 
the  nerves  are  united  with  sutures,  and  then,  if  advisable,  the  dura  is  opened. 
The  Opening  of  the  Dura. — In  the  majority  of  instances  it  is  advisable  to 
open  this  membrane  to  be  assured  of  the  condition  of  the  cord.  However, 
the  principles  relating  to  removal  of  depressing  agents  of  the  brain  can  be 
applied  with  satisfactory  outcome  to  the  cord.  The  dura  may  be  opened  at 
the  median  line  with  forceps  and  scalpel  for  a  sufficient  distance  to  permit  the 
examination  of  its  contents.  The  subdural  space  is  explored  carefully  in  all 
directions  with  a  bent  silver  probe,  to  determine  the  presence  of  disease  or 
injury.  Tumors  are  removed  if  not  infiltrating,  and  bony  irregularities,  spic- 
ulae,  and  diseased  products  are  similarly  treated.  All  efforts  to  repair  the 
cord  itself  have  as  yet  proved  futile.  Whether  or  not  the  theca  should  be 
sutured  after  treatment  of  the  contents  depends  not  a  little  on  the  nature 


314 


OPERATIVE  SURGERY. 


and  extent  of  the  disease  and  the  character  of  the  products  disclosed.  In 
some  instances  of  large  tumors  both  Horsley  and  Keen  omitted  the  closure. 
If  infecting  agencies  be  already  present  within  the  membranes,  closure  of 
the  dural  incision  should  be  omitted  and  suitable  drainage  be  established  in- 


FiG.  329. — Removal  of  bone  pressure. 

stead.  The  liability  to  fistulous  formation,  which  may  happen  in  any  event, 
is  increased  with  non-sewing  of  the  membranes,  and  this  occurrence  invites 
infection  and  is  often  of  perplexing  duration.  The  escape  of  cerebro-spinal 
fluid  in  such  cases  is  often  excessive  and  dangerous,  but  not  so  much  on 
account  of  the  loss  of  fluid  as  of  the  irritation  and  annoyance  imposed, 
and  the  increased  liability  of  infection.  A  fine  needle  armed  with  silk  or 
catgut  is  used  for  suturing.  If  a  coarse  one  be  employed,  the  punctures 
may  permit  the  escape  of  the  fluid,  and  thus  invite  fistulous  formation,  de- 
layed union,  and  consequent  infection.  Employ  deep  drainage  for  a  day  or 
two,  and  longer  if  advisable ;  unite  the  deeper  layers  of  muscles  with  buried 
catgut  sutures,  close  the  integumentary  wound  with  silkworm  gut,  apply 
abundant  antiseptic  dressings,  fix  them  with  a  firmly  applied  binder,  and 
place  the  patient  on  the  back.  Remove  the  dressings  in  twenty- four  hours, 
or  sooner  if  soiled.  Thereafter  renew  them  with  aseptic  care  as  often  as 
is  consistent  with  the  comfort  and  security  of  the  patient. 

The  Osteoplastic  Flap. — The  making  of  an  osteoplastic  flap  is  preferred 
by  some  surgeons,  with  the  view  of  securing  greater  solidity  of  the  spine 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


315 


after  recovery.  There  appears  to  be  as  yet  no  good  reason  for  this  propo- 
sition, except  perhaps  in  case  of  Pott's  disease,  in  which  the  bodies  of  the 
vertebra  are  not  sufficiently  solidified  to  properly  support  the  trunk  in  the 
absence  of  excised  laminae  and  spinous  processes.  However,  it  is  deemed 
proper  to  sa}^,  even  in  this  connection,  that  a  flap  of  this  kind,  when  employed 
in  stationary  or  advancing  Pott's  disease,  can  scarcely  be  expected  to  unite 
at  the  bony  points ;  and  it  will,  moreover,  be  illy  fitted  to  meet  the  demands 
of  drainage  and  the  prevention  of  infection,  to  say  nothing  of  the  greater 
operative  dangers  attending  its  formation.  The  osteoplastic  flap  is  quadri- 
lateral, attached  above,  and  includes  the  laminas  or  spinous  processes  which 
are  cut  away  and  turned  upward  along  with  it  (Fig.  330) .    The  construction 


ElG.  330.— Osteoplast  I 

of  the  flap  is  difficult  and  tedious,  and  necessarily  attended  with  a  greater 
loss  of  blood  than  is  the  former  method.  If  the  latter  be  employed,  the 
bony  asperities  should  be  removed  before  replacement,  and  the  osseous 
fragments  sutured  in  j)lace,  if  possible,  before  final  union  of  the  soft  parts 
is  made. 


316 


OPERATIVE  SURGERY. 


The  Results. — Of  270  cases  reported  by  Genet,  53  recovered.  Chipault 
analyzed  160  cases,  with  the  following  results:  20  were  cured,  33  improved, 
22  unimproved,  65  died,  and  in  20  the  results  are  unknown.  The  death  rate 
of  laminectomy  for  Pott's  disease  is  about  forty  per  cent. 

Spinal  Meningeal  Drainage. — The  draining  away  of  the  cerebro-spinal 
fluid  with  a  small  trocar  inserted  between  the  lamina  of  the  cervical  or 
lumbar  vertebrae,  or  at  the  seat  of  a  primary  laminectomy,  for  the  relief 
of  pressure  in  cerebral  disease,  has  of  late  been  practiced  to  a  considerable 
extent.    The  lumbar  region  is  the  one  commonly  selected  for  the  purpose. 

TJie  Anatomical  Points. — As  the  spaces  immediately  connected  with  the 
lamina  of  the  fourth  lumbar  vertebrae  are  the  ones  through  which  the  pro- 
cedure is  commonly  conducted,  it  will  not  be  amiss  to  direct  attention  to 
certain  anatomical  facts  concerned  in  the  operation  at  these  points.  In 
infants  these  spaces  have  a  transverse  diameter  of  about  three  quarters  of 
an  inch  and  a  vertical  of  about  half  an  inch,  the  latter  being  increased  by 
flexion  of  the  spine.    The  requisite  depth  of  the  puncture  is  about  four  fifths 

of  an  inch  in  infants;  in 
adults  it  is  twice  that  dis- 
tance. The  lumbo-sacral 
space  being  the  larger,  and 
farthest  removed  from  the 
spinal  nerves,  is  recom- 
mended as  a  suitable  place 
for  puncture  (Chipault). 
The  Operation. — Ad- 
minister an  anesthetic ; 
place  the  patient  in  the  sit- 
ting posture  with  the  body 
slightly  flexed;  make  a 
short  incision  down  to  the 
bone  at  the  point  through 
which  the  puncture  is  to 
be  made,  and  introduce 
the  trocar  slowly  and  con- 
tinuously into  the  spinal 
canal  (Fig.  331).  Various 
directions  are  given  to  the 
trocar,  as,  forward  toward  the  median  line,  A  (Quincke),  upward  and  for- 
ward between  and  along  the  course  of  the  spinous  processes,  B  (Marfan), 
and  upward  and  forward  through  the  lumbo-sacral  space  at  either  side  of 
the  spinous  process,  C  (Chipault),  D  (Tuffier). 

Parkin's  Operation  (Fig.  332). — Parkin  proposed,  in  lieu  of  spinal  punc- 
ture, to  enter  the  basal  subarachnoidan  space  by  trephining  the  occipital 
bone  (c)  at  a  point  low  enough  to  permit  tapping  of  the  subarachnoid  space 
{a,h)  under  the  cerebellum.  The  comparative  success  thus  far  attained  by 
Parkin  certainly  encourages  continued  effort  in  this  direction. 

The  Results. — Five  cases  are  reported,  with  three   recoveries. 


Fig.  331. — The  different  directions  of  introducing  a 
trocar  in  spinal  drainage.  A.  Quincke's.  B.  Mar- 
fan's.    C.  Chipault's.     D.  TufBer's. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


!17 


Fig.  332. — The  opening  in  the  skull  in  Parkin's 
operation. 


The  curative  effects  of  spinal  drainage  are  not  of  a  reassuring  char- 
acter. However,  amelioration  of  the  symptoms  frequently  follows,  which 
of  itself  is  comforting,  and  may  offer  the  way  to  the  only  chance  for  re- 
covery. The  importance  as  a  diagnostic  measure  appears  to  rest  on 
a  substantial  foundation. 
The  ojieration  alone  pre- 
sents no  especial  dangers 
if  cautiously  and  aseptic- 
ally  performed. 

Spina  Bifida.  —  Spina 
bifida  is  a  not  infrequent 
defect,  since  it  is  noted  in 
one  in  about  eight  hun- 
dred births.  It  may  ap- 
pear at  any  portion  of  the 
vertebral  column,  but  most 
frequently  in  the  lumbo- 
sacral region.  The  defect 
may  involve  one  or  more 
of  the  laminae,  and  rarely, 
indeed,  even  the  body  of 
a  vertebra  itself.  Three  varieties  of  arrangement  of  the  tissues  involved 
are  noted,  viz. :  1,  in  which  the  membranes  alone  protrude  (meningocele) ; 
2,  in  which  both  the  membranes  and  cord  protrude  (meningo-myelocele) ;  3, 
in  which  to  the  latter  condition  is  added  distention  of  the  central  canal  of 
the  cord,  reducing  the  cord  to  a  thin  internal  covering  lying  against  the 
membranes  (syringomyelia).  These  tumors  vary  also  in  size  and  shape, 
being  large  and  small,  and  sessile  and  pedunculated  in  form. 

If,  after  two  or  three  months,  palliative  treatment  affords  no  relief  or  the 
symptoms  increase  in  gravity,  one  of  two  measures  of  radical  cure  should  be 
attempted — i.  e.,  injection  or  excision. 

The  Injection  Method. — The  iodoglycerin  solution  is  advised  especially 
for  use  in  this  method  (page  230).  After  complete  antiseptic  preparation,  the 
patient  is  placed  on  the  side  and  an  anaesthetic  is  given  if  necessary.  The 
needle  is  introduced  as  far  from  the  median  line  of  the  tumor  as  possible,  in 
order  to  avoid  puncturing  the  nervous  tissue  and  also  to  utilize  the  soundest 
integumentary  covering,  and  while  pressure  is  made  on  the  neck  of  the  sac. 
A  drachm  or  two  of  fluid  is  drawn  from  it — suflBcient  to  cause  perceptible 
relaxation — followed  by  the  slow  introduction  of  a  drachm  or  a  drachm  and 
a  half  of  the  iodoglycerin  fluid.  This  fluid  may  remain  or  be  permitted  to 
escape  and  distilled  water  be  introduced,  the  needle  withdrawn  and  the 
opening  so  closed  as  to  prevent  the  escape  of  fluid  and  carefully  protect  the 
puncture.  If  the  communication  between  the  sac  and  the  cord  be  small, 
long,  or  closed,  the  danger  of  the  injection  method  is  proportionately  dimin- 
ished. If,  however,  the  opening  to  the  sac  be  large  and  the  capacity  of  the 
sac  be  small,  then  the  amount  injected  should  be  lessened  and  the  caution 
in  the  use  increased.     The  slight  reaction  that  follows  in  favorable  cases  sub- 


318  OPERATIVE  SURGERY. 

sides  within  two  weeks,  when  a  second  injection  may  be  employed.  Spinal 
meningitis  due  to  infection  or  to  the  medication  may  ensue.  Ulceration 
may  follow  at  the  point  of  puncture,  leading  to  the  escape  of  the  cerebro- 
spinal fluid  and  to  death  from  convulsions  or  infective  meningitis. 

The  EesuUs. — The  death  rate  is  from  twenty-seven  to  twenty-eight  per 
cent.  Repeated  injections  are  sometimes  needed  to  effect  a  cure.  In  about 
seven  per  cent  of  the  cases  no  effect  is  noticed. 

The  Excision  Method. — The  treatment  of  spina  bifida  by  excision  is  now 
regarded  with  comparatively  great  favor  by  the  majority  of  surgeons.  It  is 
applicable,  however,  only  to  the  first  two  varieties  of  the  anomaly,  the  simple 
meningocele  being  the  best  adapted  to  the  procedure.  The  advantages  of 
thorough  asepsis  are  of  superlative  importance  in  this  operation. 

In  meningocele  an  elliptical  incision  is  made  down  to  the  sac,  leaving 
sufficietit  integument  at  either  side  to  close  the  defect.  The  sac  is  exposed 
down  to  the  base,  and  if  the  neck  be  small  it  is  ligatured  with  silk  or  strong 
catgut  and  removed,  and  the  wound  closed  and  dressed  in  the  usual  manner. 
If  the  neck  of  the  sac  be  large  it  should  be  sutured  through  and  through 
with  silk  or  catgut,  so  as  to  bring  the  serous  surfaces  in  apposition  with  each 
other,  carefully  avoiding  in  the  meantime  the  escape  of  cerebro-spinal  fluid, 
not  so  much  on  account  of  immediate  as  of  subsequent  danger  to  life  from 
infective  meningitis,  the  result  of  a  fistulous  communication  with  spinal 
membranes.    Division  of  skin  and  sac  in  same  course  weakens  union. 

The  EesuUs. — The  number  of  cases  thus  far  treated  is  considerably  over 
one  hundred,  with  a  rate  of  mortality  varying  from  twenty  to  twenty-six  per 
cent,  showing  somewhat  better  results  than  follow  the  injection  method. 

Meningo-myelocele. — In  this  variety  of  infliction  the  spinal  nerves  play 
an  important  part,  as  it  is  necessary  to  eliminate  them  from  the  remainder 
of  the  tumor  and  return  them  to  the  spinal  canal.  More  commonly  the 
nerves  are  associated  with  the  posterior  wall  of  the  sac,  but  when  present 
within  it  they  are  more  frequently  adherent  at  either  side  of  the  median  line 
of  the  tumor.  In  both  instances  the  sac  is  approached  the  same  as  in  me- 
ningocele, the  nerves  dissected  out  and  returned  to  the  spinal  canal,  and  the 
sac  treated  as  in  the  preceding  instance.  The  difficulty  attending  the  elim- 
ination of  the  nerves  from  the  tumor  without  great  damage  to  the  sac,  free 
escape  of  cerebro-spinal  fluid  and  subsequent  fatal  meningitis,  is  manifest. 
Nerves  that  are  limited  to  the  tumor  alone,  or  perchance  pass  outside,  may 
be  removed  entirely ;  but  all  those  that  may  be  replaced  in  the  spinal  canal 
should  be  treated  with  scrupulous  care  and  be  returned  to  their  normal  en- 
vironment. If  the  establishment  of  a  fistulous  opening  with  the  spinal  canal 
be  regarded  imminent,  suitable  drainage  should  be  provided,  and  every  anti- 
septic measure  rigorously  enforced  to  prevent  meningitis  and  lessen  its  dan- 
ger. In  other  respects  the  wound  is  treated  by  common  aseptic  methods. 
The  great  desideratum  is  the  proper  strengthening  of  the  posterior  wall  of 
the  spinal  canal,  and  it  is  in  this  line  of  achievement  that  modern  surgical 
effort  has  been  directed.  The  union  in  the  median  line  of  detached  muscles 
at  either  side  of  the  spine  (Bayer) ;  similar  union  of  the  forcibly  detached 
rudimentary  arches  of  the  dorsal  (Dollinger)  and  sacral  (Senenko)  verte- 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  319 

brae ;  the  employment  of  a  portion  of  the  iliac  crest  (Bobroff)  while  attached 
to  the  erector  spinas  muscle ;  the  utilization  of  foreign  periosteum  or  bone, 
are  each  advised.  The  last  has  been  tried,  but  the  outcome  can  not  be  re- 
garded with  the  favor  that  characterizes  autoplasty.  The  use  of  the  celluloid 
plate,  sprung  into  place,  offers  a  comparatively  encouraging  outlook. 

Tlie  Results. — The  operative  outcome  in  meningo-myelocele  is  so  un- 
favorable that  many  authorities  discourage  the  attempt. 

Tumors  of  the  Spinal  Cord. — The  prospect  for  relief  in  some  forms  of 
this  affection  is  not  discouraging.  Tumors  of  the  membranes  of  the 
cord  and  those  outside  are  favorably  situated  for  operation.  Circumscribed 
tumors  of  the  cord  offer  a  degree  of  hope  of  relief  over  the  diffuse  variety. 
A  knowledge  of  the  technique  of  laminectomy,  plus  that  of  the  removal 
of  tumors  of  the  brain,  meets  the  requirements  of  surgical  procedure  of 
the  cord. 

The  Results. — About  fifty  per  cent  recover  from  the  operation  ;  but  as 
yet  it  is  impracticable  to  express  in  numbers  the  functional  benefits  thus  far 
received. 

The  Spinal  Accessory  Nerve. — The  spinal  accessory  nerve  is  subjected  to 
the  various  surgical  means  directed  to  the  cure  of  torticollis. 

The  Anatomical  Points. — After  escaping  from  the  jugular  foramen,  the 
nerve  runs  in  front  of  the  jugular  vein,  beneath  the  digastric  and  stylo-hyoid 
muscles  and  the  occipital  artery,  and  enters  the  deep  portion  of  the  anterior 
border  of  the  sterno-mastoid  at  a  point  about  two  inches  below  the  tip  of 
the  mastoid  process.  It  then  passes  obliquely  downward  and  backward  in 
the  structure  of  the  muscle  to  the  center  of  the  posterior  border,  escapes  and 
crosses  the  lower  part  of  the  occipital  triangle,  passes  beneath  the  anterior 
border  of  the  trapezius  muscle  at  the  upper  part  of  the  lower  third,  and 
disajopears  in  the  muscular  structure.  The  nerve  can  be  exposed  at  either 
the  upper  or  lower  portions. 

The  Operation  (upper  portion). — Eaise  the  shoulders,  extend  the  head, 
and  turn  the  face  to  the  opposite  side  ;  make  an  incision  from  the  tip  of  the 
mastoid  process  along  the  anterior  border  of  the  sterno-mastoid  muscle  (Fig. 
216)  three  inches  in  length ;  divide  the  integument  and  superficial  fascia ; 
expose  the  anterior  border  of  the  sterno-mastoid  muscle  and  divide  the  deep 
cervical  fascia ;  flex  the  head  slightly,  draw  the  sterno-mastoid  outward, 
thus  making  the  nerve  tense  and  appreciable  to  touch  ;  expose  the  nerve 
with  thumb  forceps  and  scissors  and  carry  around  it  and  tie  a  strong  liga- 
ture ;  stretch  the  nerve  and  divide  it  at  either  side  of  and  as  far  from  the 
ligature  as  is  practicable.  Close  and  dress  the  wound  in  the  usual  manner 
and  keep  the  head  quiet.  The  nerve  can  he  exposed  in  the  loioer  portion  of 
the  occipital  triangle  at  the  posterior  border  of  the  sterno-mastoid  (Fig.  214). 
It  is  then  followed  upward  until  the  posterior  border  of  the  sterno-mastoid 
is  reached  and  resected  ;  or  resection  is  done  before  it  enters  the  sterno- 
mastoid,  depending  on  the  effect  desired.  The  writer  once  approached  the 
nerve  by  going  between  the  anterior  fibers  of  the  sterno-mastoid.  The  nerve 
was  quickly  and  easily  reached  before  it  entered  the  muscle,  and  the  wound 
healed  promptly. 


320  OPERATIVE  SURGERY. 

The  Remarhs. — Division  of  the  nerve  is  followed  quite  soon  by  atrophy 
of  the  muscles,  attended  with  drooping  of  the  shoulder.  Irritation  of  the 
nerve  on  exposure  with  the  forceps  will  cause  contraction  of  the  trapezius, 
even  with  the  patient  under  anaesthesia,  a  fact  of  manifest  diagnostic  im- 
portance. 

The  EesuUs. — Stretching  and  simple  division  of  the  nerve  do  but  little 
good ;  neurectomy,  however,  is  followed  by  a  fair  degree  of  success. 

Operations  on  the  Branches  of  the  Cervical  Nerves. — Many  of  the  branches 
arising  from  the  anterior  and  posterior  cervical  plexuses  are  treated  surgically 
for  the  cure  of  neuralgia  and  spasmodic  affections. 

Excision  of  the  Posterior  Divisions  of  the  First  Three  Cervical  Nerves 
(Keen). — This  operation  is  advised  for  the  relief  of  spasmodic  wryneck  de- 
pendent on  the  action  of  the  posterior  rotator  muscles  of  the  head. 

The  Operation. — Make  a  transverse  incision  three  inches  in  length  from 
half  an  inch  below  the  lobe  of  the  ear  to  the  middle  line  of  the  neck  pos- 
teriorly ;  divide  the  trapezius  transversely  (Fig.  231) ;  recognize  the  occipi- 
talis major  nerve  as  it  escapes  from  the  complexus  muscle  half  an  inch  below 
the  line  of  incision ;  divide  the  complexus  transversely  on  the  level  with  the 
nerve ;  expose  the  nerve  down  to  its  origin  from  the  inner  division  of  the 
posterior  trunk  of  the  second  cervical  nerve  ;  resect  this  division  as  low  as 
possible  to  paralyze  the  inferior  oblique  muscle ;  recognize  and  divide  the 
suboccipital  nerve  as  it  passes  outward  across  the  arch  of  the  atlas,  carefully 
avoiding  the  vertebral  artery.  An  inch  below  the  second  is  found  the  third 
branch  of  this  plexus — i.  e.,  the  internal  division  of  the  posterior  trunk  of  the 
third  cervical  nerve.  This  operation  is  one  in  which  a  knowledge  of  anat- 
omy will  do  much  to  facilitate  the  efforts  and  comfort  the  operator.  The 
wound  is  dressed  as  in  other  cases,  and  the  head  fixed  until  repair  takes 
place. 

The  Results. — Nothing  can  as  yet  be  said  of  this  operation,  except  that  in 
cases  calling  for  it  the  outlook  should  be  quite  as  favorable  as  in  those  cases 
already  benefited  by  a  similar  proceeding  elsewhere. 

The  occipitalis  major  can  be  divided  or  stretched  higher  up  in  its  course 
than  is  indicated  above,  if  desirable. 

The  Operation. — Locate  the  occipital  protuberance,  and,  beginning  about 
an  inch  above  the  protuberance,  make  an  incision  one  inch  and  a  half  in 
length  downward,  forward,  and  outward  at  its  anterior  border ;  carefully 
separate  the  tissues  in  the  line  of  the  incision,  and  the  nerve  will  be  exposed 
where  it  escapes  from  beneath  the  trapezius  muscle. 

The  Auricularis  Magnus  Nerve. — This  nerve  is  one  of  the  ascending 
branches  of  the  cervical  plexus.  It  emerges  at  the  posterior  border  of  the 
sterno-mastoid  muscle  near  its  middle,  and  ascends  on  that  muscle  to  the 
lobule  of  the  ear  (Fig.  216). 

The  Operation. — Make  an  incision  two  inches  in  length  obliquely  up- 
ward and  backward,  its  center  corresponding  to  the  lower  extremity  of  the 
lobule  of  the  ear.  On  dividing  the  skin  and  fascia  the  nerve  will  be  found 
resting  on  the  sterno-mastoid  muscle,  from  which  it  can  be  raised  with  a 
hook  and  stretched  or  cut. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM. 


321 


Intraspinal  Division  of  the  Roots  of  Spinal  Nerves  (brachial  plexus). — 
This  operative  procedure  was  first  performed  by  Abbe,  and  for  the  relief  of 
intractable  neuralgia  of  the  brachial  plexus. 

The  Operation. — Locate  the  vertebral  spinous  processes  that  correspond 
to  the  nerves  to  be  attacked ;  place  the  patient,  and  ojjen  the  spinal  canal 
and  dura,  as  in  laminectomy ;  identify  the  posterior  roots  of  the  affected 
nerves  and  resect  from  each  as  long  'a  segment 
as  practicable,  dividing  the  corresponding  anterior 
roots  (Fig.  333) ;  close  the  dura  mater  by  sewing 
with  catgut  ;  unite  the  wound  as  indicated  in 
laminectomy. 

The  Remarhs. — The  operation  is  in  all  essential 
regards  similar  to  laminectomy  aside  from  the  sur- 
gical treatment  of  the  roots  of  the  nerves.  Care- 
fully indicate  on  the  skin  the  spinous  processes 
that  correspond  to  the  nerves  involved  before  be- 
ginning the  operation. 

The  Results. — Several  cases  have  been  thus 
treated,  but  with  an  outcome  not  at  all  encourag- 
ing so  far  as  relief  from  pain  is  concerned.  The 
operation  itself  can  be  regarded  as  free  from  dan- 
ger in  the  presence  of  proper  aseptic  technique. 

The  Branches  of  the  Brachial  Plexus. — It  may 
be  necessary,  on  account  of  a  severe  neuralgia  in- 
volving the  branches  of  this  plexus  directly,  or 
located  in  a  painful  stump,  to  excise  or  stretch 
the  nervous  cords  near  their  origin.  It  is  best 
done  at  the  seat  of  the  three  primary  branches. 

TJie  Operation. — Place  the  patient  upon  the 
back,  raise  the  shoulders,  and  turn  the  head  back- 
ward and  to  the  opposite  side.  Determine  the 
course  of  the  external  Jugular  by  pressure  just 
above  the  clavicle ;  make  an  incision  along  the 
posterior  border  of  the  sterno-mastoid  three  inches 
in  length  extending  down  to  the  clavicle ;  a  second 
incision  of  the  same  length  is  made  outward  from 

this  point,  along  the  upper  border  of  the  clavicle,  carefully  avoiding  the  ex- 
ternal jugular ;  turn  the  flap  upward  and  seek  for  the  posterior  belly  of  the 
omo-hyoid  ;  when  found,  draw  it  upward  with  a  hook  or  ligature,  push  aside 
the  loose  connective  tissue,  and  the  cords  will  appear  located  above  and  to 
the  outer  side  of  the  third  portion  of  the  subclavian  artery,  which  should 
be  carefully  avoided.  The  inner  cord  is  cautiously  hooked  up  and  a  ligature 
applied  to  it,  by  which  it  can  be  raised  from  its  bed  and  stretched,  then 
divided  with  a  pair  of  scissors  near  the  outer  border  of  the  scalenus  anticus 
muscle,  being  careful  to  avoid  the  muscle  and  the  phrenic  nerve.  If  gentle 
traction  be  made  upon  the  ligature,  the  distal  extremity  will  be  raised,  and 
can  be  again  divided  an  inch  or  so  from  the  point  of  the  first  section  and 


5Ilj  C 


61"  C 


7IH  C 


SUJ  C 


l-SJ  D 

Fig.  333. — Intraspinal  divi- 
sion of  the  roots  of  spinal 


322 


OPERATIVE  SURGERY. 


the  portion  removed.    The  remaining  cords  can  then  be  divided  in  the  same 
manner. 

The  Musculo-Cutaneous  Nerve. — The  musculo-cutaneous  nerve  can  be 

exposed  at  two  situations :  1.  As 
it  escapes  from  the  axilla.  2. 
Near  to  the  elbow  joint. 

The  Operation. — At  the  first 
situation,  carry  the  arm  from  the 
body  and  rotate  it  outward ;  make 
an  incision  three  inches  in  length 
along  the  inner  border  of  the  co- 
raco-brachialis  muscle  (Fig.  219) ; 
divide  the  skin  and  fascia  on  a 
director,  draw  the  muscle  inward, 
and  the  nerve  will  be  easily  found 
at  its  inner  border.  The  nerve 
is  exposed  at  a  lower  point  than 
this,  after  perforating  the  coraco- 
brachialis  muscle,  by  making  the 
incision  at  the  outer  border  of 
that  muscle. 

At  the  second  situation  it  is 
found  by  making  an  incision  two 
and  a  half  inches  in  length  be- 
tween the  biceps  and  the  supina- 
tor longus,  through  the  integu- 
ment, fascia,  and  aponeurosis; 
separate  the  muscles  and  the 
nerve  will  be  readily 
seen  (Fig.  222,  f). 

The  Musculo- 
Spiral  Nerve. — The 
musculo  -  spiral 
nerve  can  be  exposed  at  three  situa- 
tions: 1.  Make  an  incision  about  four 
inches  in  length  between  the  outer 
border  of  the  triceps  and  the  brachia- 
lis  anticus  muscles  (Fig.  334),  beginning  two  and  a  half  inches 
above  the  external  condyle.  Divide  the  fascia  on  a  director,  sepa- 
rate the  connective  tissues  with  a  handle  of  a  scalpel  or  the  finger, 
and  the  nerve  will  be  easily  found.  2.  Make  an  incision  three  or 
four  inches  in  length  at  the  inner  aspect  and  upper  third  of  the 
arm  (Fig.  219).  The  tendon  of  the  latissimus  dorsi  above,  the  long  head  of 
the  triceps  muscle  at  the  inner,  and  superior  profunda  artery  at  the  outer, 
mark  the  situation  of  the  nerve.  An  incision  made  at  the  posterior  and 
inferior  aspect  of  the  upper  third  of  the  arm,  located  below  the  deltoid  and 
passing  between  the  outer  and  long  heads  of  the  triceps,  promptly  exposes 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


323 


to  view  the  nerve,  attended 
by  the  superior  profunda 
artery  (Fig.  334).  3.  Make 
an  incision  three  inches  in 
length  in  the  space  between 
the  supinator  longus  and 
the  brachialisanticus  mus- 
cles ;  divide  the  fascia,  sep- 
arate the  connective  tissues 
beneath  it,  and  the  nerve 
will  be  readily  exposed. 

The  Circumflex  Nerve. 
— Abduct  the  arm  and  press 
the  posterior  border  of  the 
deltoid  muscle  toward  the 
surgical  neck  of  the  hume- 
rus,notingthe  angle  formed 
by  this  and  the  posterior 
scapular   muscles ;   expose 
the  posterior  border  of  the 
deltoid  through  a  longitu- 
dinal incision  made  at  this 
point;  draw  theborder  for- 
ward and  expose  the  lower 
edge  of  the  teres  minor  and 
the  long  head  of  the  triceps, 
and  observe  in  the  angle 
between  them  the  circum- 
flex nerve  attended  by  the 
posterior  circumflex  artery 
(Fig.  334).     The  circum- 
flex nerve  can  be  exposed 
near  its  origin  through  an 
incision  carried  from  the 
beginning  of  the  arm  along 
the  axillary  surface  of  the 
posterior  axillary  fold.  Di- 
vide the  fascia;  separate  the 
loose  cellular  tissue  at  the 
upper  borders  of  the  inser- 
tion of  the  latissimus  dorsi 
and  teres  major  muscles. 
At  the  upper  end  of  the 
incision  will  be  seen  the 
circTimflex  nerve,  with  the 
scapular  vessels  and  nerves 
on  a  lower  plane  (Fig.  319). 


FAT  UPON  THE) 
TENDON    OF    [ 
FLEXOR 
5UBLIMI5 

TENDON  OF 
FLEXOR  CARPI 

RADIALI5.I  i: 


PRONATOR 
TERES . 


FLEXOR  CARPI 
ULNARIS. 


FLEXOR 
PROFUNDUS  01  Sm 


I  TENDON    OF 
[PALMARIS  LONG. 


Fig.  335.— Median  nerve  in  the  forearm. 


324  OPERATIVE  SURGERY. 

The  Median  Nerve. — The  median  nerve  can  be  easily  exposed  in  its 
course  along  the  arm  by  modifying  either  of  the  incisions  for  ligaturing  the 
brachial  to  correspond  to  the  relations  of  the  median  nerve  to  that  vessel 
(Figs.  219  and  222,  /). 

In  the  forearm,  the  median  nerve  can  be  exposed  at  three  situations :  1, 
at  the  upper  third ;  2,  below  the  middle ;  3,  above  the  wrist  joint. 

At  the  upper  third,  supinate  the  arm  and  make  an  incision  as  for  liga- 
ture of  the  radial  artery  at  that  situation  (Fig.  335)  ;  divide  the  pronator 
radii  teres  and  the  tendinous  arch  of  the  flexor  sublimis  digitorum,  thus 
exposing  the  nerve  contiguous  to  which  lies  the  anterior  interosseous  branch. 

Below  the  middle  the  nerve  is  exposed  through  an  incision  made  between 
the  flexor  carpi  radialis  and  the  palmaris  longus  muscles,  after  drawing  in- 
ward the  interposing  fleshy  belly  of  the  flexor  sublimis  digitorum.  The 
median  artery  is  present  at  this  situation. 

Above  the  wrist  joint  the  nerve  is  quickly  seen  through  an  incision  of 
the  skin  and  fascia  made  at  the  radial  side  of  the  palmaris  longus  tendon. 

The  Ulnar  Nerve  in  the  Arm. — At  the  upper  and  the  middle  thirds  of 
the  arm  this  nerve  lies  near  to  the  inner  aspect  of  the  brachial  artery,  and 
can  be  readily  exposed  at  these  situations  by  properly  located  incisions  of 
similar  dimensions  to  those  employed  to  expose  like  portions  of  the  artery 
(Fig.  219). 

The  ulnar  nerve  at  the  elbow  is  of  special  importance  because  of  its  rela- 
tions to  the  internal  condyle  and  to  the  olecranon  process  (Fig.  223,  J)  in 
connection  with  excision  of  the  joint,  and  also  its  liability  to  injury  and  dis- 
placement at  this  situation. 

Displacement  of  the  ulnar  nerve  is  rare.  However,  this  condition  may 
complicate  fracture  or  dislocation  at  the  elbow,  and  it  may  arise  from  other 
causes. 

MacCormac  advises  that  the  nerve  be  exposed  by  a  free  incision,  dividing 
the  tissues  back  to  the  inner  condyle,  thus  providing  a  bed  into  which  the 
dislocated  nerve  is  placed  and  fastened  by  sutures  of  kangaroo  tendon  passed 
through  the  borders  of  the  wound  and  the  triceps  tendon. 

The  radial  and  ulnar  nerves  in  the  forearm  can  be  easily  exposed  through 
the  incisions  employed  to  ligature  the  vessels  bearing  similar  names  (Fig.  222). 

-Branches  of  the  Sacral  Plexus. — The  gluteal,  pudic,  and  small  sciatic 
nerves  can  each  be  exposed  through  the  same  incisions  used  to  ligature  the 
arteries  of  a  similar  name  (Fig.  185). 

The  Great  Sciatic  Nerve. — The  great  sciatic  nerve,  though  lying  deeply, 
can  be  reached  through  the  incision  for  ligatureof  the  sciatic  artery  (Fig.  185). 

At  the  posterior  surface  of  the  thigh  this  nerve  can  be  exposed  just 
below  the  gluteal  fold  and  at  the  seat  of  bifurcation  (Fig.  336)  ;  it  is  best 
approached  after  its  escape  from  beneath  the  lower  border  of  the  gluteus 
maximus. 

The  Operation. — Place  the  patient  on  the  abdomen  or  side,  and  make  an 
incision  three  or  four  inches  in  length,  beginning  at  the  gluteal  fold,  at  a 
point  midway  between  the  tuber  ischii  and  the  trochanter  major,  or  the  ver- 
tical incision  may  be  joined  by  a  short  horizontal  incision;  divide  the  in- 


OPERATIONS  ON  THE   NERVOUS  SYSTEM. 


325 


tegument  and  fascia  on  a  director,  separate  tlic  connective  tissue  with 
the  fingers  and  handle  of  the  scalpel  clown  to  tlie  nerve,  hringing  into 
view  the  biceps  muscle,  small  sciatic  nerve,  etc.  (Fig.  33(i).    It  can  then  be 


W 

BICEPS.- 

INT.  AND  EXT. 
POPLITEAL  NS. 

\  l- 
SEMITENDINOSUS- 

t 

% 

TENDON  OF  BICEPS.  --J;:  ,:        // 
£XT.  POPLITEAL  N — W~--f{!j- 

gastrocnemius]    -'- 
(outer  head.) 

fascia  lata. 


Fig.  336. — Exposure  of  great  sciatic  and  popliteal  nerves. 


stretched  by  passing  one  or  two  fingers  around  it  and  making  firm  and 

steady  traction  upon  it  (sufficient  to  raise  the  limb).    The  wound  should  be 

carefully  closed  and  dressed  under  antiseptic  precautions. 
23 


826 


OPERATIVE  SURGERY. 


GREAT  SCIATIC  N 


The  Bloodless  Stretching  of  the  Sciatic. — Administer  an  ansesthetic  and 
place  the  patient  on  the  back  or  side.  Extend  the  leg  fully  on  the  thigh,  and 
hold  the  pelvis  firmly.  Flex  the  thigh  on  the  pelvis  while  full  extension  of 
the  leg  on  the  thigh  is  continued,  thus  causing  extreme  tension  of  the 
muscles  and  other  structures  on  the  posterior  surface  of  the  thigh,  thereby 
stretching  the  nerve.    The  manipulation  must  be  firmly  yet  cautiously  made 

to  attain  the  object,  and  at 
the  same  time  not  tear  asun- 
der the  hamstring  muscles. 
At  the  Seat  of  Bifurca- 
tion (Fig.  337).— At  this 
situation — just  below  the 
middle  of  the  thigh — the 
nerve  is  exposed  through  an 
incision  directed  between 
the  semitendinosus  and 
semimembranosus  muscles 
internally,  and  the  biceps 
externally.  It  lies  deeply, 
near  the  posterior  surface 
of  the  femur,  and  may  have 
divided  already  into  its  ter- 
minal branches  (Fig.  192). 
The  Fallacy.  —  Earely 
this  nerve  divides  into  its  ter- 
minal branches  in  the  pelvis, 
presenting,  therefore,  two 
branches  at  either  site  of 
operation.  Some  confusion 
may  occur  in  its  detection 
and  incomplete  treatment  of 
the  affliction  result,  if  this  ab- 
normality be  not  discovered. 
The  Results. — Obstinate 
sciatica  has  been  relieved, 
and  even  cured,  by  stretch- 
ing. Not  infrequently  the 
degree  of  the  resulting  ec- 
chymosis  indicates  rupture  of  the  muscular  structures  in  bloodless  stretching. 
The  Internal  Popliteal  Nerve. — The  internal  popliteal  nerve  can  be 
reached  by  the  same  method  and  with  the  same  caution  as  the  popliteal 
artery  (Fig.  336).  It  is,  however,  less  deeply  situated  and  somewhat  nearer 
the  center  of  the  popliteal  space  than  are  the  vessels  (Fig.  195).  Extreme 
caution  should  be  exercised  in  operating  upon  it,  on  account  of  its  nearness 
to  the  popliteal  vein,  which  lies  beneath  it  and  to  the  inner  side. 

The  External  Popliteal  Nerve. — The  external  popliteal  nerve  can  be 
easily  reached  by  making  an  incision  two  or  three  inches  in  length  along 


Fig.  337. — Incisions  in  exposure  of  great  sciatic  and 
branches. 


OPERATIONS  ON  THE  NERVOUS  SYSTEM.  327 

the  inner  side  of  the  tendon  of  the  biceps  cruris  (Figs.  330  and  337),  when 
the  nerve  can  be  readily  found  beneath  the  fascia,  surrounded  by  fat  (Fig. 
190,  J). 

The  anterior  and  posterior  tibial  nerves  can  be  exposed  and  stretched 
through  the  incisions  adopted  in  ligaturing  the  vessels  of  the  same  names 
(Figs.  198  and  203). 

The  Plantar  Nerves. — The  plantar  nerves  are  the  terminal  branches  of 
the  posterior  tibial,  and  are  given  off  just  after  the  nerve  winds  around  the 
internal  malleolus.  They  can  be  exposed  by  making  an  incision  about  three 
inches  in  length,  beginning  just  in  front  of  the  center  of  a  line  extending 
from  the  anterior  border  of  the  internal  malleolus  to  the  inner  tuberosity 
of  the  OS  calcis,  and  carried  forward  along  the  external  border  of  the  ab- 
ductor pollicis.  If  the  space  between  the  short  flexor  and  the  abductor  be 
now  opened  at  the  posterior  portion,  the  nerves  will  be  found  accompanied 
by  the  arteries  of  a  similar  name. 

The  Perineal  Nerve. — The  perineal  nerve  may  be  exposed  in  the  peri- 
neeum  of  the  male  by  making  an  incision  along  the  ramus  of  the  pubes  and 
ischium  at  either  side  in  the  same  manner  as  directed  for  ligaturing  the 
pubic  artery  at  this  situation  (Fig,  187).  In  the  female  perinseum  the  nerve 
may  be  exposed  either  by  an  incision  made  without  or  within  the  vagina.  In 
the  former  instance,  make  it  through  the  superficial  tissues,  about  three 
inches  in  length,  in  the  groove  between  the  labium  and  the  perinseum,  just 
inside  the  rami  of  the  pubes  and  ischium.  The  nerve  is  surrounded  by  con- 
nective tissue,  and  it  is  difficult  to  find  in  this  situation;  however,  if  the 
blade  of  the  knife  be  turned  inward  and  the  outer  coats  of  the  vagina  be 
divided  down  to  the  inner  one,  the  nerve  will  not  escape  section. 

The  nerve  is  more  easily  severed  from  within  the  vagina.  If  the  finger 
be  introduced  an  inch  or  more  and  lateral  pressure  be  made,  the  nerve  will 
be  felt,  cordlike  in  character  and  sensitive  to  the  touch.  Make  a  vertical 
incision  through  the  coats  of  the  vagina,  and  the  nerve  will  be  exposed  for 
division  or  excision. 

The  Branches  of  Lumbar  Plexus. — Operations  on  the  branches  of  this 
plexus  are  not  practiced  as  frequently  as  on  those  of  the  other  plexuses. 

The  Anterior  Crural  Nerve. — The  anterior  crural  nerve  is  the  largest 
branch  of  the  lumbar  plexus,  and  enters  the  thigh  beneath  Poupart's  liga- 
ment, about  three  quarters  of  an  inch  to  the  outer  side  of  the  femoral  artery. 
It  lies  beneath  the  iliac  fascia  (Fig.  338). 

The  Operation. — Make  an  incision  three  inches  in  length  directly  down- 
ward, beginning  about  an  inch  below  Poupart's  ligament,  in  the  line  of  the 
nerve.  The  superimposed  layers  of  tissue  are  carefully  divided  on  a  director 
down  to  the  groove  between  the  iliac  and  psoas  muscles,  between  which  it 
rests.  The  pulsations  of  the  femoral  artery  will  always  suggest  the  location 
of  the  nerve. 

The  Obturator  Nerve  (Fig.  189). — The  obturator  nerve  and  artery,  and 
the  internal  circumflex  branch  of  tlie  profunda  artery,  are  each  exposed 
through  a  vertical  incision  beginning  just  below  and  a  finger's  breadth  in- 
side of  the  center  of  Poupart's  ligament.     The  integument  and  fascia  are 


328 


OPERATIVE  SURGERY. 


divided  carefully,  avoiding  the  internal  saphenous  vein.  Divide  the 
pectineal  fascia  j^^st  external  to  the  femoral  vein,  define  the  border  of  the 
pectineus  muscle  and  separate  the  muscle  from  the  pubis  and  obturator 
fascia,  and  draw  it  inward.  Divide  the  obturator  fascia,  pass  the  finger 
above  the  upper  border  of  the  obturator  muscle,  and  feel  for  the  artery  and 
nerve  as  they  pass  through  the  obturator  foramen  under  the  horizontal 
ramus  of  the  pubis. 

The  Internal  or  Long  Saphenous  Nerve  is  given  ofE  from  the  anterior 
crural,  and  supplies  the  inner  surface  of  the  leg.  It  is  accompanied  by  a 
vein  of  the  same  name  in  its  course  along  the  leg.  It  can  be  reached  easily 
at  many  situations,  but  practically,  however,  it  is  best  exposed  at  the  inner 
condyle  of  the  femur,  where  it  escapes  from  beneath  the  sartorius  (Fig.  203), 
and  at  the  middle  of  the  leg.    At  the  former  situation  recognize  the  tendon 

of  the  sartorius.  Press  upon  the 
internal  saphenous  vein  above 
this  point  to  distend  it;  make 
an  incision  two  inches  in  length 
close  to  and  parallel  with  the 
vein,  draw  it  aside,  and  the 
nerve  will  be  found  emerging 
from  beneath  the  tendons  of  the 
sartorius  and  gracilis.  At  the 
middle  of  the  leg  (Fig.  200,  F) 
make  an  incision  three  inches 
in  length  parallel  with  the  prop- 
erly distended  vein,  which  should 
then  be  pulled  aside,  and  the 
nerve  will  be  found  close  to  and 
behind  the  vein. 

The  External  or  Short  Sa- 
phenous Nerve  (Figs.  204,  c,  and  337)  arises  from  the  internal  popliteal, 
escapes  from  between  the  heads  of  the  gastrocnemius,  pierces  the  fascia  be- 
low the  middle  of  the  leg  and  becomes  subcutaneous,  and  passes  down  on 
the  fibular  side  of  the  posterior  surface  to  the  malleolus,  accompanied  by  the 
external  saphenous  vein.  Distend  the  vein  by  pressure;  make  an  incision 
close  to  and  parallel  with  it,  near  the  border  of  the  tendo  Achillis ;  pull  the 
vein  aside,  and  the  nerve  will  be  seen. 


Pig.  338. — Anterior  ciural  nerve  exposed,  a 
Femoral  artery,  n.  Anterior  crural  nerve,  pi 
Psoas  and  iliac  muscles,    s.  Sartorius  muscle. 


CHAPTER   VII. 

OPERATIONS  ON  TENDONS,   LIGA3IENTS,   F ASCI  AS,  MUSCLES,  AND 

BURS^. 


Tekdons,  mnscles,  ligaments,  and  fascias  suffer  often  from  the  effects  of 
strain  and  rupture,  and  from  chronic  disease,  and  various  degrees  of  defor- 
mity and  modified  function  of  parts  are  frequent  sequels.  The  remedial 
measures  directed  to  the  alleviation  of  the  effects  of  these  pathological  con- 
ditions on  tendinous  and  muscular  tissues  are  tenotomy,  tendon  suture,  tendon 
transplantation,  tendon  lengthening^  tendon  shortening,  tendon  anastomosis, 
and  myotomy. 

The  bursal  structures  are  of  great  mechanical  importance  in  the  human 
economy,  and  are  subject  to  different  grades  of  inflammation  and  degrees  of 
traumatic  violence,  for  the  relief  from  which  various  operations  are  prac- 
ticed. 

Tenotomy. — Tenotomy  consists  in  making  a  subcutaneous  or  open  divi- 
sion of  a  tendon  for  the  purpose  of  overcoming  or  alleviating  a  deformity 
dependent  usually  on  muscular  contraction.     Since  the  advent  of  antiseptic 
surgery  open  division  can  be  practiced   with    com- 
parative impunity  if  a  rigid  adherence  to  its  tenets 
be  maintained.     However,  it  is  wiser  to  hold  to  the 
subcutaneous   method   than   to  invite  unnecessarily 
the   mishaps  that  may  follow  a  faulty  technique  in 
the  open  one.     In  order  to  practice  tenotomy  sue-        iV       l\      I\      )\. 
cessfully  the  exact  location  of  the  offending  structure 
should  be  determined,  together  with  the  important 
contiguous  vessels,  nerves,  etc.     Many  of  the  large 
tendons  are  easily  located  by  their   natural   promi- 
nence.    Others  that  ordinarily  lie  concealed  become 
apparent  if  contraction  and  deformity  have  occurred, 
and  still  more  conspicuous  if  placed  upon  the  stretch 
by  the  surgeon.     The  principles  governing  tenotomy 
should  be  well  considered  before  a  tendon  is  divided, 
otherwise  an  expedient  of  great  good  may  become        Yio.  339.— Tenotomes, 
mischievous  and  even  destructive  in  its  results. 

The  instruments  employed  in  tenotomy  are  few  in  nunilx'r  and  simple  in 
character.  Fig.  339  represents  the  tenotomes  in  ordinary  use.  They  are 
excellent  instruments  for  the  purpose.  Fig.  340,  representing  the  ordinary 
tenotome  found  in  the  pocket  cases  of  the  day,  is  usually  too  fragile  to  be 
safely  employed  in  the  division  of  tissues  requiring  any  special  outlay  of 

339 


330 


OPERATIVE  SURGERY. 


Fig.  340. — Pocket-case  tenotome. 


force,  as  the  delicate  point  is  liable  to  be  broken  if  brought  in  contact  with 
tough,  fibrous  or  bony  tissue ;  moreover,  it  is  with  difficulty  made  aseptic. 

The  Operation. — The  operation  of  tenotomy  is  simplified  by  attention  to 
the  following  order  of  procedure  : 

1.  Secure  complete  aseptic  technique. 

2.  Indicate  on  the  handle  of  the  scalpel  the  direction  of  the  cutting 
edge. 

3.  Carefully  note  the  length  of  the  blade,  so  as  to  regulate  the  extent  of 
the  division  of  the  tissues. 

4.  Avoid,  if  possible,  the  division  of  a  tendon  as  it  passes  through  a  special 
sheath. 

5.  Divide  the  tendon  at  the  point  of  greatest  forced  prominence,  pro- 
vided the  division  be  consistent  with  the  safety  of  important  contiguous 

structures.     If  reflex 


spasm  be  provoked 
by  "point  pressure," 
the  tendon  should  be 
divided  at  the  point 
exhibiting  the  great- 
est reflex  manifesta- 
tion (Sayre). 

6.  Make  tense  the 

structure  to  be  divided,  and  so  pinch  up  or  push  aside  the  skin  at  the  point 
of  proposed  division  that  when  the  skin  is  relaxed  the  opening  in  it  will 
not  correspond  to  the  divided  tendon. 

7.  Insert  the  blade  on  the  flat  close  to  the  surface  of  the  tendon  to  be 
divided ;  turn  the  edge  toward  the  tendon  and  carefully  sever  it  with  a 
guarded  sawing  motion,  aided  by  pressing  the  tendon  on  the  cutting  surface 
of  the  knife.  If  incautious  force  be  made,  not  only  the  tendon  but  the 
superimposed  tissue  may  be  divided,  thus  complicating  the  treatment  and 
recovery. 

8.  Carry  the  edge  of  the  blade /rom  important  structures  when  possible. 

9.  Withdraw  the  blade  while  upon  the  flat ;  follow  the  withdrawal  with 
firm  pressure  upon  the  parts  with  the  thumb,  which  should  finally  rest  on 
the  incision.  This  act  will  press  the  blood  and  air  from  the  wound,  as  well 
as  prevent  air  from  entering  it.  Close  the  wound  with  a  catgut  stitch  and 
seal  it  with  antiseptic  collodion.  The  application  and  confinement  to  the 
wound  of  an  antiseptic  pad  is  often  quite  sufficient  for  the  requirements  of 
healing. 

10.  Kectify  the  deformity,  and  confine  the  part  immovably  until  repair 
is  well  advanced. 

The  degree  of  rectification  is,  according  to  some  authorities,  regulated  by 
the  size  of  the  divided  tendon ;  the  smaller  the  tendon  the  completer  should 
be  the  degree  of  restoration,  and  vice  versa.  If  the  tendon  be  closely  asso- 
ciated with  important  structures,  it  is  advised  to  use  the  sharp-pointed  teno- 
tome to  prepare  the  way  for  the  blunt-ended  one  with  which  the  abnormal  tis- 
sues are  then  divided,  and  with  less  danger  than  if  the  former  be  used  through- 


OPERATIONS  ON  TENDONS,  LIGAMENTS,  PASCIAS,  ETC.  331 

out.  The  injection  into  the  tissue  adjacent  to  the  tendon  of  an  aseptic  solu- 
tion of  cocaine  will  reduce  the  pain  of  the  procedure  to  a  minimum. 

Tenotomy — Upper  Extremities.  The  Division  of  the  Tendons  of  the 
Flexor  Sublimis  and  Flexor  Profundus  Digitorum  Muscles. — These  tendons 
can  be  divided  at  the  middle  of  the  first  row  of  anatomical  phalanges  by  a 
transverse,  subcutaneous  incision  carried  through  them  down  to  the  bone. 
After  division  of  the  tendons,  reduce  tli|^  deformity  and  keep  the  parts 
quiet  for  five  or  six  days  till  the  danger  from  inflammation  has  subsided, 
when  they  may  be  cautiously  moved.  Aseptic  precautions  should  be  ob- 
served throughout,  otherwise  inflammation  of  the  sheaths  of  the  tendons  will 
follow. 

The  Divisio7i  of  the  Tendons  of  the  Extensor  Communis  Digitorum 
Muscle. — The  tendons  of  this  muscle  can  be  readily  divided  as  they  pass 
along  the  carpus  and  upon  the  dorsum  of  the  phalanges.  In  the  former 
instance  pinch  up  the  skin,  pass  the  knife  beneath  the  tendon,  as  before 
directed,  and  cut  toward  the  surface.  They  may  be  divided  by  passing  the 
blade  above  the  tendons  and  cutting  down  through  them  upon  the  bone. 
On  the  dorsum  of  the  phalanges  the  blade  should  be  passed  beneath  the  skin 
and  the  tendons  divided  upon  the  bone. 

The  Precautions. — In  the  division  of  the  tendons  of  both  flexor  and  ex- 
tensor muscles,  the  carpal  joints,  the  palm  of  the  hand  above  the  transverse 
line  (Fig.  504),  the  course  of  the  vessels,  and  the  spaces  between  the  meta- 
carpal bones  should  be  avoided. 

The  Division  of  the  Tendons  of  the  Extensor  JBrevis,  Lotigus,  and  Ossis 
Metacarpi  Pollicis  Muscles. — These  tendons  can  readily  be  made  prominent 
simultaneously  or  in  turn  by  forcible  extension  with  alternate  supination 
and  pronation  of  the  thumb,  with  the  forearm  midway  between  supination 
and  pronation.  The  brevis  and  ossis  metacarpi  pollicis  tendons  form  the 
inner  boundary  of  the  "  snulfbox "  at  the  apex  of  the  styloid  process  of 
the  radius,  the  ossis  metacarpi  pollicis  being  the  more  internal  of  the  two. 
The  tendon  of  the  extensor  longus  pollicis  forms  its  outer  boundary.  These 
tendons  can  be  divided  at  this  situation  by  making  them  as  prominent  as 
possible,  then  introducing  the  knife  from  the  anterior  surface  of  the  wrist 
beneath  the  tendon  and  cutting  toward  the  integument. 

The  Precautions. — The  radial  artery  is  to  be  avoided  as  it  passes  be- 
neath them,  and  likewise  the  radicle  of  the  radial  vein  as  it  crosses  the  in- 
tervening space. 

The  Division  of  the  Tendon  of  the  Flexor  Carjn  Radialis  Mtiscle. — The 
tendon  of  this  muscle,  at  the  lower  third  of  the  forearm,  is  situated  imme- 
diately to  the  inner  side  of  the  radial  artery,  and  can  be  readily  divided  there 
by  passing  the  knife  away  from  the  artery  beneath  the  tendon. 

The  Division  of  the  Tendon  of  the  Flexor  Carpi  Ulnaris  Muscle. — The 
tendon  of  the  flexor  carpi  ulnaris,  the  most  internal  on  the  anterior  sur- 
face of  the  forearm,  is  inserted  largely  into  the  pisiform  bone  and  has  the 
ulnar  artery  at  the  outer  border.  This  tendon  can  be  easily  divided  at  a 
half  inch  or  so  above  the  insertion  by  passing  the  knife  beneath  it,  away 
from  the  artery  and  nerve,  and  cutting  toward  the  surface. 


332  OPERATIVE  SURGERY. 

The  Division  of  the  Tendon  of  the  Biceps  Muscle  of  the  Forearm. — The 
tendon  of  insertion  of  this  muscle  may  be  divided  either  above  or  below  the 
giving  off  of  the  bicipital  fascia  (Fig.  222^  f).  The  former  situation  is  the 
safer.  Division  at  the  latter  point  contemplates  the  leaving  intact  of  the 
bicipital  fascia.  This  is  a  matter  of  some  importance,  for  if  the  fascia  is 
contracted  also,  the  deformity  will  be  maintained  in  lesser  degree  after  sec- 
tion of  the  tendon  at  the  lower  point.  But  when  the  fascia  is  not  involved, 
some  advantage  will  be  gained  in  pronation  of  the  forearm  if  the  influence 
of  the  fascia  be  not  impaired  by  section. 

The  Operatio7i. — Make  the  veins  at  the  elbow  prominent  by  constricting 
the  arm  above  ;  extend  the  forearm  to  make  the  tendon  prominent  and 
tense  ;  enter  the  knife  at  its  inner  border  and  pass  it  cautiously  between  the 
tendon  and  the  brachial  artery ;  cut  outward,  being  careful  not  to  injure 
the  distended  veins. 

Tenotomy — Lower  Extremities.  The  Division  of  the  Tendon  of  the 
Tibialis  Posticus  Muscle. — The  tendon  of  this  muscle  is  intimately  associ- 
ated with  the  deformity  of  talipes  varus.  It  runs  along  the  inner  border  of 
the  tibia,  behind  the  internal  malleolus,  in  a  separate  sheath,  being  the  inner- 
most tendon  at  this  situation  ;  after  leaving  the  internal  malleolus  it  passes 
beneath  the  calcaneo-scaphoid  ligament  to  its  insertions.  In  the  normal 
foot  it  lies  well  concealed  within  a  closely  fitting  groove,  but  it  can  be  readily 
outlined  between  the  tip  of  the  malleolus  and  the  astragalo-scaphoid  articu- 
lation. 

In  talipes  varus  the  tendon  is  raised  from  its  groove  and  becomes  promi- 
nent above  and  below  the  tip  of  the  internal  malleolus.  The  tendon  can  be 
divided  either  above  or  below  the  malleolus,  but  it  is  better  done  at  a  point 
about  an  inch  and  a  half  above  the  tip  in  the  adult,  and  one  inch  in  the 
child  or  infant.  The  tendon  is  made  tense  by  strongly  abducting  the  foot, 
and  the  knife  is  passed  with  the  usual  precautions  between  the  internal  bor- 
der of  the  tibia  and  the  tendon  ;  the  division  is  made  by  cutting  backward. 

The  division  between  the  tip  of  the  malleolus  and  the  astragalo-scaphoid 
articulation  is  not  advised  on  account  of  the  contiguity  of  the  ankle  joint 
and  the  internal  plantar  artery.  If,  however,  it  be  thought  advisable  to 
operate  at  this  situation,  the  foot  should  be  strongly  abducted,  the  point  of 
the  tenotome  carefully  insinuated  beneath  the  tendon  between  it  and  the 
plantar  artery ;  the  handle  is  then  depressed  so  as  to  carry  the  point  away 
from  the  joint,  and  the  section  made  from  within  outward.  In  fat  infants 
it  often  happens  that  neither  the  tendon  nor  the  inner  edge  of  the  tibia  can 
be  located.  In  such  cases  a  puncture  is  made  in  a  line  exactly  between  the 
anterior  and  posterior  borders  of  the  leg  at  the  inner  aspect  with  a  sharp- 
pointed  tenotome  down  to  and  through  the  sheath  of  the  tendon.  The  sharp- 
pointed  blade  is  then  withdrawn  and  a  blunt-pointed  one  is  passed  beneath 
the  tendon,  which  is  divided  by  cutting  upward.  It  is  wise  to  recall  the 
fact  that  while  the  space  between  the  tendon  and  the  tarsal  bones  is  of  lim- 
ited extent,  yet  it  is  quite  sufficient  to  admit  the  blade  of  the  tenotome. 

The  Division  of  the  Tendon  of  the  Flexor  Longus  Digitorum  Muscle. 
— The  tendons  of  this  muscle  are  sometimes  productive  of  flexion  of  the 


OPERATIONS   ON   TENDONS,  LIGAMENTS,  PASCIAS,  ETC.  333 

toes,  after  the  correction  of  the  deformity  of  the  tarsus  caused  by  the  con- 
traction of  the  tibialis  posticus.  The  flexor  longus  digitorum  tendon  lies 
immediately  posterior  to  the  tendon  of  the  tibialis  posticus,  behind  the  inter- 
nal malleolus,  and  is  often  divided  by  the  same  cut  which  severs  the  tendon 
of  that  muscle.     It  can,  however,  be  divided  independently. 

If,  after  the  division  of  the  tibialis  posticus  tendon,  the  influence  of  the 
flexor  longus  digitorum  muscle  on  the  toes  be  objectionable,  its  tendon 
can  be  divided  by  introducing  the  tenotome  beneath  it  through  the  same 
incision,  and  cutting  toward  the  surface  as  before. 

The  Precautions. — The  posterior  tibial  artery  and  its  venas  comites, 
which  in  the  adult  are  often  varicose  in  this  situation,  must  be  carefully 
avoided  by  pressing  them  outward  with  the  finger.  If  for  contraction  of  the 
toes,  unassociated  with  deformity  due  to  the  tibialis  posticus,  it  be  deemed 
advisable  to  sever  the  tendon  of  this  muscle,  the  posterior  tibial  vessels 
must  first  be  detected  and  pushed  outward  by  the  thumb,  which  should  then 
be  pressed  firmly  between  them  and  the  tendons  at  the  inner  side  ;  then  pass 
the  tenotome  perpendicularly  through  the  integument,  midway  between  the 
internal  margin  of  the  tibia  and  the  end  of  the  thumb  ;  carefully  insinuate 
it  between  the  tendons  of  the  tibialis  posticus  and  the  flexor  longus  digito- 
rum down  to  the  bone  ;  turn  the  edge  toward  the  surface,  and  carefully 
divide  the  tendon, 

Tlie  Division  of  the  Tendon  of  the  Flexor  Longus  Pollicis  Muscle. — It 
may  become  necessary  to  divide  the  tendon  of  this  muscle  on  account  of  the 
crippled  action  of  the  foot  in  walking  dependent  upon  undue  flexion  of  the 
great  toe.  The  .toe  should  be  forcibly  extended,  and  the  knife  carefully 
inserted  beneath  the  tendon  at  the  point  of  greatest  prominence,  which  will 
be  anteriorly  at  the  inner  border  of  the  foot.  The  blade  of  the  instrument 
should  be  passed  from  the  internal  plantar  artery. 

Tlie  Tendo  Achillis  is  the  largest  and  most  prominent  tendon  of  the 
human  system.  It  is  about  six  inches  long,  three  quarters  of  an  inch 
broad,  and  a  quarter  of  an  inch  thick,  and  is  inserted  into  the  lower  part  of 
the  posterior  tuberosity  of  the  os  calcis.  The  narrowest  portion  in  the  adult 
is  at  a  point  about  two  inches  above  the  insertion.  The  posterior  tibial  ves- 
sels and  nerves  are  to  the  front  and  inner  side  at  a  considerable  distance 
from  the  tendon,  and  in  no  danger  of  injury  if  ordinary  care  be  exercised. 
The  short  saphenous  vein  lies  superficially  and  closely  to  the  outer  border. 

The  Division  of  the  Tendo  Achillis. — Place  the  patient  on  a  bed  with  the 
foot  extending  over  the  edge ;  forcibly  flex  the  foot  to  make  the  tendon 
tense  (Fig.  3-il) ;  draw  the  skin  outward  away  from  the  tendon  to  remove 
the  saphenous  vein  from  danger ;  introduce  the  blade  of  the  tenotome  with 
the  flat  surface  parallel  with  the  tendon  close  to  its  outer  or  inner  border,  as 
is  most  convenient;  carry  the  point  of  the  blade  to  the  opposite  side  of  the 
tendon  and  depress  the  handle  to  a  horizontal  position  ;  turn  the  edge 
toward  the  tendon  and  cut  carefully  through  the  structure  with  a  guarded 
sawing  motion,  while  the  foot  is  firmly  flexed  and  the  tendon  is  pressed 
upon  the  edge  with  the  finger.  At  the  last  stage  of  the  procedure  great 
caution  is  essential,  otherwise  a  sudden  giving  way  of  the  tendon  may  cause 


334 


OPERATIVE  SURGERY. 


the  severance  of  the  superimposed  tissues.  All  of  the  precautions  pre- 
viously enjoined  in  tenotomy  should  be  exercised  in  this  instance.  After 
carefully  pressing  the  air  and  blood  from  the  wound  by  carrying  the  thumb 
and  finger  of  the  left  hand  toward  the  cut,  the  wound  is  closed  by  a  catgut 
stitch  or  by  an  antiseptic  compress  held  in  place  by  a  fold  of  sterile 
gauze.     When  the  position  of  the  foot  is  properly  rectified,  it  should  be 


Fig.  341. — Dividing  tendo  Achillis. 


held  thus  (Fig.  342)  by  a  long  adhesive  strip  (2,  3)  carried  up  the  leg 
from  a  thin  strip  of  wood  (4)  strapped  (1)  to  the  sole  of  the  bandaged  foot 
and  held  in  position  by  adhesive  plaster  or  bandages.  A  thin  plaster-of- 
Paris  splint  applied  to  the  leg  and  foot  with  the  latter  in  the  rectified  po- 
sition will  hold  them  in  proper  relation.  If 
gradual  rectification  be  practiced,  these  re- 
straining influences  should  not  be  employed 
until  three  or  four  days  later. 

The  Division  of  the  Tendons  of  the  Per- 
oneus  Longus  and  Brevis  Muscles. — The 
tendons  of  these  muscles  pass  in  a  common 
groove  behind  the  external  malleolus,  and  are 
inclosed  by  the  same  sheath,  the  brevis  pass- 
ing the  more  anteriorly.  The  peroneus  brevis 
leaves  its  fellow  after  passing  behind  the  mal- 
leolus, and  is  inserted  into  the  base  of  the 
metatarsal  bone  of  the  little  toe  at  the  outer 
side.  The  peroneus  longus,  after  passing  be- 
hind the  malleolus,  gains  the  sole  of  the  foot, 
enters  the  calcaneo-cuboid  groove,  and  is  in- 
serted into  the  internal  cuneiform  and  the 
base  of  the  metatarsal  bone  of  the  great  toe, 
at  the  outer  side.  The  tendon  of  either  mus- 
cle may  be  divided  at  two  situations:  1, 
About  an  inch  and  a  half  above  the  tip  of 
the  malleolus;  2,  at  three  fourths  of  an  inch  in  front  of  the  malleolus. 
These  tendons  are  commonly  divided  at  the  former  situation,  but  can  be 
severed  connectedly  or  singly  at  either  place. 


Fig. 


342.— Foot,  rectified  and  held 
in  position. 


OPERATIONS  ON  TENDONS,  LIGAMENTS,  FASCTAS,  ETC.  335 

If  it  be  decided  to  sever  both  simultaneously  ubove  the  malleolus,  seek 
the  antero-external  border  of  the  fibula  about  an  inch  and  a  half  above  its 
tip;  pass  the  knife  between  the  bone  and  tendons;  turn  the  edge  outward 
and  cut  toward  the  surface.  The  short  saphenous  vein  should  be  pushed 
inward  to  avoid  injury. 

If  either  tendon  is  to  be  divided  separately  above  the  malleolus,  push  the 
integument  aside  with  the  thumb  to  protect  the  vein,  then  push  the  thumb 
down  firmly  to  the  bone  behind  the  tendons ;  pass  the  tenotome  perpen- 
dicularly at  the  end  of  the  thumb  and  carefully  insinuate  it  between  the 
tendons,  after  which  it  is  passed  outward  or  inward,  as  the  case  may  be, 
beneath  the  tendon  to  be  severed,  the  edge  turned  toward  the  surface,  and 
the  division  made  as  in  the  preceding  instances. 

If  the  division  is  to  be  made  below  the  malleolus,  make  the  tendons  tense ; 
enter  the  knife  about  one  half  or  three  fourths  of  an  inch  in  front  of  the  tip 
of  the  malleolus,  between  the  tendons,  when  either  may  be  divided  by  cut- 
ting outward  or  inward,  as  the  case  may  be. 

The  Division  of  the  Tendon  of  the  Tibialis  Ajiticus  Muscle. — The  ten- 
don of  this  muscle,  like  the  tibialis  posticus,  is  of  importance  in  connection 
with  talipes  varus.  It  is  the  innermost  tendon  of  the  leg  and  foot  on  their 
anterior  surface,  and  can  be  easily  outlined  unless  the  foot  be  fat  and  chubby, 
when  some  difficulty  may  be  experienced. 

In  well-marked  cases  of  talipes  varus  the  tendon  is  displaced  considerably 
to  the  inner  side,  and,  if  the  foot  be  abducted,  will  become  quite  prominent. 
It  is  best  divided  about  one  inch  above  its  insertion  into  the  internal  cunei- 
form bone.  Make  the  tendon  tense  and  pass  the  knife  from  without  inward, 
to  avoid  the  dorsalis  pedis  vessels. 

The  Division  of  the  Tendon  of  the  Extensor  Proprius  Hallucis  Muscle. 
— As  the  tendon  of  this  muscle  passes  across  the  dorsum  of  the  foot,  it  can, 
like  the  preceding  tendon,  be  quite  easily  distinguished.  It  may  be  necessary 
to  divide  it  after  the  division  of  the  extensors  of  the  tarsus,  on  account  of  its 
causing  undue  extension  of  the  great  toe.  The  toe  should  be  forcibly  flexed 
and  the  tenotome  carried  beneath  the  tendon  from  without  inward,  to  avoid 
the  dorsalis  pedis  vessels. 

The  Division  of  the  Tendons  of  the  Extensor  Longus  Digitorum  Muscle. 
— The  tendons  of  this  muscle  may  cause  not  only  an  obstinate  extension  of 
the  toes,  but  may  also  aid  in  maintaining  the  tarsus  in  a  state  of  forced 
flexion.  They  can  be  divided  separately,  as  they  pass  along  the  dorsum  of 
the  foot,  or  all  may  be  cut  at  once  by  flexing  the  toes,  entering  the  knife 
beneath  the  tendons  a  little  below  the  bend  of  the  ankle,  from  within  out- 
ward, to  avoid  the  dorsalis  pedis  vessels. 

The  Division  of  the  Tendon  of  the  Peroneus  Tertius  Muscle. — The 
peroneus  tertius  may  be  divided  together  with  the  extensor  longus 
digitorum  tendons.  It  can  be  divided  separately  before  its  insertion  into 
the  dorsum  of  the  metatarsal  bone  of  the  little  toe  by  extending  the 
tarsus  and  passing  the  knife  beneath  it  from  without  inward.  It  is  the 
most  external  tendon  on  the  dorsum  of  the  foot  in  front  of  the  external 
malleolus. 


336  OPERATIVE  SURGERY. 

The  Division  of  the  Biceps  Tendon  at  the  Leg. — The  tendon  of  the  biceps 
cruris  forms  the  external  hamstring,  and  is  inserted  into  the  head  of  the 
fibula  and  the  outer  tuberosity  of  the  tibia.  The  external  popliteal  nerve 
is  located  immediately  at  its  inner  side  (Fig.  196^  J).  To  divide  the  tendon 
extend  the  leg,  press  the  nerve  aside  with  the  thumb,  and  pass  the  tenotome 
from  within  outward  beneath  the  tendon  about  an  inch  and  a  half  above  the 
head  of  the  fibula,  and  divide  the  tendon  toward  the  surface  while  it  is  sup- 
ported by  the  finger. 

The  Inner  Hamstring  Tendons  are  the  tendons  of  the  semitendinosus, 
semimembranosus,  gracilis,  and  sartorius  muscles ;  the  first  two,  however, 
are  the  ones  principally  concerned  in  deformities.  The  tendon  of  the  semi- 
tendinosus is  the  longest,  smallest,  and  nearest  to  the  median  line  of  the 
popliteal  space ;  that  of  the  semimembranosus  is  much  deeper  and  runs 
parallel  with  the  former.  Either  of  these  tendons  can  be  divided  by  extend- 
ing the  leg  to  make  the  tendon  tense,  and  entering  the  knife  beneath  it 
from  the  outer  side,  at  the  most  prominent  portion,  and  cutting  toward  the 
surface. 

The  Bemarhs. — Their  division  to  relieve  flexion  of  the  leg  will  not  al- 
ways admit  of  its  complete  extension,  due,  among  other  things,  to  the  con- 
traction of  the  heads  of  the  gastrocnemius,  which  are  inserted  into  the 
condyles  of  the  femur.  The  forced  extension  of  the  leg  under  these  cir- 
cumstances often  causes  the  tearing  asunder  of  the  attachments  of  this  mus- 
cle, especially  the  inner  head,  which  is  the  larger  and  stronger  and  is  inserted 
higher  than  the  external.  The  haBmorrhage  resulting  therefrom  may  be 
severe  enough  to  infiltrate  the  tissues  of  the  popliteal  space,  thus  simulating 
rupture  of  more  important  vessels.  The  liability  to  this  rupture  and  conse- 
quent bleeding  may  be  lessened,  if  not  obviated,  by  first  dividing  the  tendo 
Achillis  ;  or,  what  is  perhaps  better,  by  first  dividing  the  hamstring  tendons, 
after  which  if,  on  attempting  to  straighten  the  limb,  the  foot  becomes  ex- 
tended, the  tendo  Achillis  can  then  be  divided.  After  division  of  the  ham- 
string tendons,  fibrous  bands  and  bands  formed  by  tense  nerves  and  vessels 
may  be  apparent  to  sight  and  touch  in  the  popliteal  space.  The  external 
popliteal  nerve  is  often  made  quite  prominent  by  the  act  of  extension,  and 
for  this  reason  may  be  mistaken  for  undivided  fibers  of  the  biceps  tendon. 
Forced  extension  in  the  presence  of  great  and  vigorous  deformity  exposes 
the  popliteal  vessels  to  the  danger  of  rupture,  and  often  causes  pain  and 
other  disagreeable  modifications  of  sensation  of  the  areas  supplied  by  the 
overstrained  nerves. 

The  Division  of  the  Tendons  of  the  Gracilis  and  Sartorius  Muscles. — 
The  gracilis  and  sartorius  tendons  can  be  divided  at  the  under  side  of  the 
knee  after  forcible  extension  of  the  leg,  by  passing  the  blade  of  the  tenotome 
close  to  the  inner  side  of  the  tendon  of  the  semimembranosus,  between  it  and 
the  gracilis,  depressing  the  handle  outward  or  inward,  as  the  case  may  be, 
and  dividing  the  structures  toward  the  skin.  The  sartorius  can  be  divided 
at  a  point  two  inches  or  so  below  its  origin.  For  this  purpose  the  thigh 
should  be  strongly  abducted,  and  a  blunt  tenotome  passed  beneath  the  mus- 
cle and  carried  toward  the  surface. 


OPERATIONS  ON  TENDONS,   LIGAMENTS,  FASCIAS,  ETC.  337 

The  Dividon  of  the  Tendon  of  the  Quddriceps  Extensor. — The  quad- 
riceps extensor  tendon  may  be  divided  above  the  patella  by  making  an  in- 
cision down  to  the  tendon  parallel  with  the  base  of  the  patella;  enter  the 
point  of  the  knife  above  the  patella  cautiously,  and  divide  the  tendon  with 
a  sawing  motion.  A  careful  and  continuous  effort  to  flex  the  leg  should  be 
made  while  the  tendon  is  being  cut,  in  order  that  its  deepest  fibers  may  be 
ruptured,  thus  avoiding,  as  far  as  possible,  entering  the  synovial  extension 
of  the  knee  joint  which  lies  beneath  it.  However,  the  limb  should  not  be 
flexed  further  than  is  necessary  for  this  purpose,  and  after  the  division  it 
should  be  placed  in  a  comfortable  position  till  repair  is  well  advanced. 

The  Division  of  the  Tendon  of  the  Adductor  Longus  Muscle. — The  ad- 
ductor longus  muscle  is  situated  at  the  inner  side  of  the  thigh,  formhig  the 
inner  border  of  Scarpa's  triangle.  It  is,  however,  located  on  about  the  same 
plane  as  the  pectiueus  muscle.  It  is  tendinous  at  its  origin  from  the  pubes, 
and  can  be  easily  divided  when  made  tense  by  passing  the  knife  beneath 
its  outer  border  an  inch  or  so  from  the  origin,  and  cutting  upward  and 
inward. 

The  Division  of  the  Pectiueus  Muscle  (Myotomy). — The  pectineus  mus- 
cle acts  as  a  flexor  and  adductor  of  the  thigh,  and  may  require  division  on 
account  of  malposition  of  the  limb.  The  pelvis  is  steadied,  the  thigh  extended 
and  abducted,  which  causes  the  fibers  of  the  pectineus  to  become  tense  and 
prominent.  A  long-bladed  myotome  (Fig.  363)  is  then  introduced  at  the 
outer  border,  about  an  inch  below  its  origin,  and  carried  inward  and  upward 
till  the  division  is  complete.  The  internal  circumflex  artery,  which  runs  be- 
tween the  psoas  magnus  and  the  outer  border  of  the  pectineus,  is  the  only 
vessel  of  any  size  exposed  to  injury.  The  danger  to  this  is  insignificant 
unless  it  arises  higher  than  usual.  If  the  division  be  made  downward  and 
inward,  the  femoral  vessels  will  be  less  exposed  than  when  made  in  the  oppo- 
site direction. 

The  Tensor  Vaginm  Femoris  Muscle  can  be  severed  without  diflBculty  by 
introducing  a  long-bladed  tenotome  beneath  it,  at  either  border,  about  an 
inch  below  its  origin,  and  cutting  toward  the  surface. 

The  Muscles  of  the  Trunk.  The  Multifidus  Spince  Muscle. — This  muscle 
lies  at  either  side  of  the  spinous  process,  in  the  groove  formed  between  the 
spinous  and  transverse  processes,  extending  from  the  sacrum  to  the  axis. 
It  is  quite  superficial  in  the  sacral  region  opposite  to  the  posterior  superior 
spinous  process  of  the  ilium. 

The  Division  of  the  Multifidus  Sjjinm  Muscle  (Myotomy). — Eaise  a  fold 
of  skin  parallel  with  the  long  axis  of  the  muscle  ;  pass  a  long-bladed  myotome 
from  the  spinous  processes  outward  beneath  the  muscle  to  its  outer  border, 
and  cut  toward  the  surface. 

The  Division  of  the  Latissimus  Dorsi. — T'he  tendon  of  this  muscle  may 
be  divided  separately  at  the  lower  border  of  the  axilla,  or  conjointly  with 
that  of  the  teres  major  muscle,  a  short  distance  below  their  insertion  into 
the  bicipital  groove  of  the  humerus. 

In  either  instance  the  arm  is  forcibly  raised  to  render  the  muscle  tense 
and  prominent,  and  a  long,  narrow-bladed  tenotome  is  inserted  along  the 


338  OPERATIVE  SURGERY. 

anterior  border,  the  edge  directed  posteriorly,  and  either  tendon  is  carefully 
severed  by  an  outward  sawing  motion. 

The  Latissimus  Dorsi  Muscle  may  be  divided  at  the  lower  angle  of  the 
scapula  in  the  following  manner  :  Make  the  muscle  tense  as  before,  pass  a 
long,  strong  tenotome  beneath  it,  and  cut  carefully  outward  toward  the  sur- 
face ;  close  the  incision  with  an  aseptic  compress. 

The  Division  of  the  Erector  Spinm  Muscle  (Myotomy). — The  erector  spinse 
muscle  forms  the  principal  portion  of  the  muscular  prominence  at  either  side 
of  the  spine  in  the  lumbar  region.  It  is  a  thick,  strong  muscle,  which  arises 
from  the  sacrum  and  contiguous  structures,  and  divides  at  the  lower  border 
of  the  last  rib  into  the  longissimus  dorsi  and  sacro-lumbalis,  which  muscles 
are  inserted  respectively  into  the  transverse  processes  of  the  dorsal  vertebrse 
and  the  angles  of  the  lower  ribs.  The  erector  spinse  can  be  divided  with 
a  long  tenotome  passed  from  the  outer  border  of  the  muscle,  just  below  the 
last  rib,  downward  and  inward  toward  the  spine. 

The  Division  of  the  Trapezius  Muscle  (Myotomy). — The  trapezius  mus- 
cle has  an  extensive  origin.  The  portion  which  arises  from  the  inner  third 
of  the  superior  curved  line  of  the  occipital  bone  is  often  divided  on  ac- 
count of  abnormal  deviations  of  the  head. 

The  division  is  readily  accomplished  by  making  the  muscle  tense,  and 
severing  it  with  a  tenotome  entered  beneath  it,  just  below  the  occipital 
protuberance,  with  the  edge  turned  toward  the  integument. 

The  Division  of  the  Sterno-Cleido- Mastoid  Muscle. — Division  of  this  mus- 
cle is  often  necessary  in  cases  of  wryneck  dependent  upon  abnormal  muscular 
force.  It  is  divided  at  its  lower  extremity,  either  at  its  sternal  or  its  clavicu- 
lar attachment,  often  at  both.  For  the  division  at  either  part,  the  muscle  is 
put  on  the  stretch  by  turning  the  head  to  the  opposite  side,  a  blunt-pointed 
tenotome  is  passed  beneath  it  from  the  outer  side,  about  half  an  inch  above 
its  insertion,  and  it  is  divided  toward  the  surface. 

The  Remarks. — The  division  of  the  clavicular  portion  may  be  ample  to 
correct  the  deformity ;  if  not,  the  sternal  portion  should  be  severed  in  the 
same  manner.  It  is  necessary  to  hug  closely  the  under  surface  of  the  por- 
tions to  be  divided,  otherwise  the  deep-seated  and  important  vessels  may  be 
injured.  It  is  not  safe  to  attempt  a  subcutaneous  section  of  the  muscle 
above  this  point  on  account  of  its  relation  to  the  common  carotid  artery  and 
the  internal  jugular  vein. 

Tenorrhaphy  or  Tendon  Suturing. — Tenorrhaphy  is  employed  for  the 
purpose  of  uniting  the  divided  ends  of  tendons  by  sewing.  General  anaes- 
thesia and  entire  absence  of  bleeding  are  essential  to  a  satisfactory  technique. 
Both  recent  and  old  divisions  are  amenable  to  this  treatment,  the  more 
recent  the  better,  however,  as  the  older  the  division  the  greater  the  degree 
of  the  separation  and  the  difficulty  of  uniting  the  divided  extremities.  It  is 
very  necessary  that  antisepsis  be  thorough,  as  a  failure  in  this  regard  not 
only  defeats  the  efforts  of  repair,  but  also  may  cause  a  destructive  inflamma- 
tion of  the  sheaths  of  the  tendons  and  contiguous  tissue. 

The  Special  Considerations. — The  chief  difficulty  of  the  operation  con- 
sists in  finding  the  divided  ends  of  the  tendons  and  uniting  them  with  their 


OPERATIONS  ON  TENDONS,  LIGAMENTS,   FASCTAS,  ETC. 


339 


Fig.  84o. — Teuoinipliy, 
simplest  method. 


fellows.  When  any  doubt  arises  regarding  their  identity,  the  ends  of  the 
tendons  of  those  muscles  having  similar  functions  should  be  joined  together. 
At  all  events,  those  having  dissimilar  functions  should  not  be  united. 
The  distal  ends  are  usually  easily  found,  as  they 
retract  but  little.  The  proximal  ends  are  often 
found  with  difficulty,  and  may  be  lost  on  ac- 
count of  strong  retraction,  especially  in  those 
cases  where  division  takes  place  during  great 
muscular  effort.  Sometimes  simple  flexion  or 
extension  of  the  limb,  as  the  case  may  be,  will  bring  them  into  view. 
The  proximal  ends  can  be  forced  downward  by  grasping  with  both  hands 
the  circumference  of  a  limb,  where  muscles  are 
divided;,  and  drawing  downward;  also  by  the  appli- 
cation of  an  Esmarch's  bandage  from  above  down- 
ward to  almost  the  seat  of  the  injury.  If  these 
measures  fail,  a  longitudinal  incision  is  made  par- 
allel with,  but  not  over  the  tendon,  for  when  thus 
approached  the  danger  of  subsequent  adhesion  of 
the  superficial  and  deep  tissues  is  reduced  to  a  mini- 


FiG.  344. — Tenorraphy,  quilt  suture. 


Fig.  345.— Witzel's  method. 


mum.  If  this  plan  be  not  feasible,  then  introduce  into  the  vacant  sheath 
up  to  the  end  of  the  tendon  a  probe,  upon  the  end  of  which  a  short  inci- 
sion is  made  from  without  down  into  the  sheath;  push  the  probe  through 
the  opening,  and  raise  the  end  of  the  tendon  through  also;  connect  the 
end  of  the  tendon  with  the  end  of  the  probe  by  means  of  a  small  cord  tied 


:0: 

Pig.  346. — a,  b,  c.  Wolfler's  quilt  suture,     d,  e.  Hueter's  peritendinous  suture. 

firmly;  withdraw  the  probe,  dragging  the  tendon  after  it  down  to  the 
open  mouth  of  the  sheath.     Silver  wire^  chromicized  catgut,  fine  silk,  and 


340 


OPERATIVE  SURGERY. 


Fig.  347.- 


-Bill  roth's  bundle- 
suture. 


kangaroo  tendon  are  acceptable  for  tendon  suturing.  The  ends  of  a  di- 
vided tendon  can  often  be  held  in  proper  place  by  means  of  one  or  more 
sutures  passed  through  them  and  tied  (Fig.  343).  If  there  be  danger  of  the 
sutures  tearing  out,  another  method  of  arrangement  may  be  used  instead 
(Fig.  344) .  Witzel's  method  is  a  simple  one  and  quickly  utilized  (Fig.  345) . 
Witzel  introduced  a  single  tendon  suture  of  medium-sized  catgut  at  a 
distance  from  the  tendon  ends,  drew  them  together  (A),  and  then  supple- 
mented this  one  by  smaller/ adjustment  sutures  (B).  The  quilt  suture  of 
Wolfler  ( Fig.  346 )  is  suited  to  meet  a  considerable  degree  of  tension.  In  in- 
stances of  great  tension,  Nicoladoni  advises  that  the  central  part  of  the  tendon 

be  fixed  to  the  integument  at  some  distance  above 
the  wound  by  a  deep  suture  or  an  acupressure 
needle,  after  which  the  ends  are  united  by  ordi- 
nary sutures.  The  central  part  can  be  stitched  to 
a  contiguous  unimpaired  tendon  with  catgut  for 
a  similar  purpose.  The  method  practiced  by 
Billroth  is,  however,  better  and  simpler  than  Nicoladoni's.  Billroth  tied 
a  suture  to  a  bundle  of  fibers  (Fig.  347)  at  either  side  of  each  end  of  the 
severed  tendon,  and  drew  the  ends  together.  When  thus  placed  the  suture 
grasps  the  fibers  at  a  right  angle  with  their  long  axis,  and  thus  obviates  the 
tearing  out  so  much  dreaded 
with  great  tension. 

Oblique  division  of  the  ex- 
tremities, and  union  by  a  su- 
ture carried  directly  through 
them  (Fig.  348),  can  be  prac- 
ticed when  the  sacrifice  of  the 
tendon  structure  in  the  accom- 
plishment of  the  coaptation 
does  not  cause  undue  shorten- 
ing. If  but  little  tendency  to  separation  be  present,  suturing  together 
the  peritendinous  tissues  of  the  extremities  may  suffice  (Hueter,  Fig.  346, 

d,  e).     However,  this  plan  is  of  infrequent  and 
uncertain  utility. 

In  order  to  bridge  an  unavoidable  gap  in  a 
tendon,  several  strands  of  fine  catgut  are  con- 
nected with  and  caused  to  extend  between  the 
separated  ends,  thus  laying  the  foundation  for  a 
possible  repair  (Fig.  349,  &).  The  introduction 
of  a  tendon  graft  in  these  cases,  of  sufficient 
length  to  fill  the  gap,  taken  from  a  cat  or  other 
suitable  source,  is  entitled  to  further  trial.  How- 
ever, if  the  tendinous  sheath  have  been  destroyed, 
ii'I  II  '111         there  is  little  chance,  indeed,  of  benefit  from  the 

last-mentioned  expedient. 

Tendon  lengthening  may  be  utilized  to  remedy 
deformities  due  to  otherwise  irremediahle  short-' 


Pig.  348. — Oblique  coaptation  of  divided  ends. 


Pig.  349. — a.  Hueter's  method, 
single  flap.  b.  Gliick's  meth- 
od, catgut  repair. 


OPERATIOXS  ON  TENDONS,  LIGAMENTS,   FASCIAS,  ETC. 


341 


ening  of  tendons  dependent  on  contraction  and  sloughing,  which  arc  often 
the  sequel  of  traumatism  and  inflammation. 

A  tendon  can  be  lengthened  by  a  single  flap  (Figs.  349,  a,  and  350),  or 
it  may  require  for  the  purpose  the 


c 


union  of  double  flaps,  one  from  the 
end  of  each  extremity  (Fig.  351). 
The  making  of  alternate  free  inci- 
sions at  the  borders  of  a  tendon — 
the  accordion  plan — so  as  to  cause 
the  tendon  to  assume  an  accordion- 
like appearance  when  lengthened 
(Fig. 353), is  much  more  ingenious 
than  practical.  Less  pronounced  cutting  (Fig.  354)  followed  by  tendon 
lengthening  is  called  the  incision  method  (Fig.  355). 


Fig,  350. — Single-flap  method. 


Fig.  351. — Double-flap  method. 

Lengthening  of  the  tendo  Achillis  to  overcome  contraction  is  sometimes 
practiced.  Through  a  free  incision  the  tendon  is  exposed  and  divided  ac- 
cording to  the  plan  of  Anderson  (Fig. 
352),  or  by  still  another  resembling  / 
Anderson's.    In  this  the  ends  a  and  b 


V^ 


Fig.  352. — Anderson's  double-flap  method. 
A.  Longitudinal  division.  B.  Flaps 
formed.  C.  Tendon  lengthened,  flaps 
united. 

are  united  together  (Fig.  356), or  the 
accordion  method  can  be  utilized. 
The  former,  however,  is  much  the 
better. 

Transplantation   upward   of   the 
24 


Fig.  853.— A.  Poncet's 
accordion  method. 


Fig.  854. — Incision 
method. 


342 


OPERATIVE  SURGERY. 


tubercle  of  the  os  colds  can  be  practiced  by  division  of  the  os  calcis  through 
a. U-shaped  incision  (Fig.  357)  made  immediately  behind  the  insertion  of 
the  tendon,  followed  by  extension  of  the  foot  and  the  nailing  together  of 
the  sawed  surfaces,  as  a  supplementary  measure  to  the  lengthening  of  the 
tendon  by  direct  method  of  practice  (Fig.  358).  However,  the  small  gain 
thus  achieved  by  the  former  is  not  commensurate  with  the  risks  incurred, 
to  say  nothing  of  the  ill  effect  of  the  measure  on  the  functions  of  the  heel. 


<, 


> 


<t 


> 


Fig.  355.— Tendon 
lengthened  in  in- 
cision method. 


Fig.  357. — Incision  for  trans- 
plantation of  tubercle  of  os 
calcis. 


Fig.  356. — Lengthening 
tendo  Achillis. 


Fig.  358.— Transplantation  of 
tubercle  of  os  calcis;  tendon 
already  lengthened. 


Tendon  shortening  is  practiced  for  the  purpose  of  improving  the  action 
of  muscles  where  power  is  lessened  by  the  elongation  of  their  tendons.  The 
removal  of  a  proper  segment  of  a  tendon  and  union  of  the  divided  extremi- 
ties can  be  accomplished  by  either  a  simple  oblique  division  and  lateral 
apposition  and  union  (Fig.  348),  or  simple  division  followed  by  intergraft- 
ing  of  the  extremities  and  union ;  i.  e.,  the  introduction  of  the  wedge-formed 
extremity  of  one  into  the  split  end  of  the  other  and  fixation  with  sutures. 

Shortening  of  the  tendo  Achillis  to  remedy  talipes  calcaneus  is  some- 
times practiced. 

Gihneyl  Method. — Expose  the  tendon  through  a  Y-shaped  incision,  di- 


OPERATIONS  ON  TENDONS,    LIGAMENTS,   FASCIAS,   ETC.  343 

vide  it  from  behind  forward  and  below  upward  very  obliquely ;  draw  the 
upper  portion  downward  as  far  as  possible  and  suture  it  to  the  lower  ;  con- 
fine the  foot  firmly  in  place  until  union  of  the  divided  ends  to  each  other 
is  secured. 

WilleWs  Method. — Make  a  Y-shaped  incision  two  inches  in  length  down 
to  the  tendo  Achillis  at  its  lower  end ;  expose  the  tendon  at  the  superficial 
and  lateral  surfaces  only,  corresponding  to  the  stem  of  the  Y ;  sever  the 
tendon  at  the  points  of  junction  of  the  vertical  portion  with  the  arms  of  the 
Y ;  dissect  along  the  deeper  surface  of  the  tendon  and  raise  the  proximal 
part  with  its  connection  to  the  integument  "intact  for  three  quarters  of  an 
inch  ;  cut  from  the  deep  surface  of  the  proximal  end  and  the  superficial 
surface  of  the  distal  one  a  wedge-shaped  slice,  with  the  base  corresponding 
to  the  point  of  transverse  division  of  the  tendon  in  each  instance  ;  press  the 
heel  upward  and  draw  down  the  proximal  portion,  thus  apposing  the  cut 
surfaces  of  the  respective  portions  with  each  other,  and  while  the  parts  are 
thus  held  pass  two  sutures  at  either  side  through  the  integument,  the  ap- 
posed extremities  of  the  tendon,  and  out  through  the  integument,  and  tie 
them  ;  unite  the  borders  of  the  integumentary  incisions  with  sutures,  leaving 
a  V-shaped  appearance  to  the  cut.    Confine  the  foot  until  repair  is  complete. 

The  Z  Method{¥ig.  359). — Expose  the  tendon  through  a  vertical  incision, 
dividing  the  skin  horizontally  at  the  upper  and  lower  ends  of  this  incision,  if 
necessary ;  divide  the  tendon  from  one  border  half- 
way through  (.4  B)  ;  split  the  tendon  from  this  point 
downward  far  enough  to  meet  the  demands  of  the  re- 
quired shortening  {B  C) ;  then  sever  the  remaining 
portion  of  the  tendon  at  a  right  angle  with  the  verti- 
cal incision  {C D)\  remove  A  B  A'  B'  and  C  D  C  D' 
from  the  respective  extremities ;  unite  the  borders  C  D 
and  C  D'  and  the  borders  A  B  and  A'  B'  with  each 
other  respectively  with  sutures,  and  also  the  vertical 
borders  B  C.  Each  part  cut  away  is  equal  in  length 
to  the  shortening  required. 

The  Remarks. — The  union  of  the  ends  of  the  ten-  Fig.  359.— Z  method  of 
don  by  sutures  after  the  removal  of  a  section  by  trans-  shortening    tendo 

verse  division  is  of  questionable  utility,  as  the  deformity 
may  soon  return  on  account  of  undue  yielding  of  the  bond  of  union  and 
the  stretching  of  the  paralyzed  muscles  of  the  calf.     In  cases  of  infantile 
paralysis  plastic  operations  on  tendons  are  useless  unless  active  fibers  be 
present  in  the  muscle,  as  indicated  by  electric  stimulation. 

Transplantation  downioard  of  the  tubercle  of  the  os  calcis,  to  overcome 
lengthening  of  the  tendo  Achillis,  can  be  practiced  by  nailing  the  posterior 
fragment  to  the  lower  rather  than  to  the  upper  aspect  of  the  sawed  surface 
of  the  anterior  fragment  (Fig.  358). 

Tendon  Transplantation  (anastomosis). — By  tendon  transplantation  move- 
ment is  imparted  to  tendons  of  paralyzed  muscles  by  grafting  them  with 
those  of  animated  muscles  having  a  similar  action.  Grafting  was  first  prac- 
ticed by  Nicoladoni  in  1883. 


344 


OPERATIVE  SURaERY. 


In  Figs.  360  and  361  the  healthy  tendon  is  situated  on  the  right,  and  is 
of  a  uniform  color,  while  the  tendon  of  the  paralyzed  muscle  is  on  the  left 
and  of  a  dotted  appearance. 

In  the  first  series  (Fig.  360)  the  tendon  of  the  muscle  from  which  the 
power  is  derived  is  functionally  unimportant. 


Fig.  360. — Tendon  transplantation.     First  series. 

In  the  second  series  the  tendon  of  the  healthy  muscle  is  functionally  im- 
portant. 

In  the  first  series  one  is  warranted  in  diverting  the  muscle  completely 
from  its  natural  course  and  making  use  of  the  entire  tendon. 


wm    mm.     imm     mm     m  na    mm      M\  i 

Fig.  361. — Tendon. transplantation.    Second  series. 

A  is  employed  where  the  muscle  is  completely  paralyzed. 

B,  C,  and  D  are  employed  where  some  function  still  remains  in  the 
paretic  muscle. 

In  the  second  series  (Fig.  361)  power  is  obtained  from  muscles  the  nor- 
mal function  of  which  can  not  be  wholly  spared  and  whose  action  therefore 
can  not  be  entirely  diverted  into  another  course.  The  continuity  of  the 
healthy  tendon  is  here  preserved. 

In  E  the  diseased  tendon  is  completely  paralyzed ;  the  healthy  tendon  is 
completely  intact. 

In  F  the  healthy  tendon  is  split  in  half;  the  diseased  tendon  is  com- 
pletely paralyzed. 

In  G  the  diseased  tendon  is  paretic ;  the  healthy  tendon  is  entirely  intact. 


OPERATIONS  ON  TENDONS,    LIGAMENTS,    FA  SCI  AS,    ETC.  34:5 

In  H  each  tendon  is  split  in  half ;  the  diseased  tendon  has  still  a  little 
power  left  in  it. 

In  /  the  healthy  tendon  is  split  in  half;  the  diseased  tendon  maybe 
either  paretic  or  completely  useless. 

The  arrows  indicate  the  directions  in  which  the  loosened  tendons  and 
parts  of  tendons  are  drawn  in  the  methods  of  transplantation. 

The  arrows  are  arranged  in  three  fashions  : 

1.  The  descending  transj)lantation  method  shows  the  arrows  pointing 
downward  toward  the  diseased  tendon  (C,  D,  I). 

2.  Tlie  '■'■  doi(ble-sided^^  transplantation  method  shows  sets  of  arrows 
pointing  toward  each  other  {A,  B,  F,  H). 

3.  The  ascending  transplantation  method  shows  arrows  pointing  from 
the  diseased  tendon  upward  toward  the  healthy  tendon  [E,  G). 

The  Operation  (Vulpius). — Lay  open  the  tendon  sheaths  by  long  parallel 
cuts,  so  that  the  strengthening  ligaments  which  hold  the  tendons  in  place 
are  saved.  The  tendons  to  be  transplanted  are  either  entirely  or  partially 
loosened  for  some  distance  in  order  to  permit  of  a  considerable  distortion. 
A  piece  of  the  muscle  belly  is  perhaps  separated  by  blunt  dissection  and  left 
in  connection  with  the  tendon. 

If  thick  tendons  lying  close  together  are  transplanted,  the  operation  is 
simple.'  If  they  are  widely  separated,  it  is  necessary  to  efEect  a  blunt  sub- 
facial  dissection.  A  forceps  is  pushed  beneath  the  soft  parts,  deep  under  the 
fascia,  because  here  deformities  of  the  tendons  are  less  to  be  feared,  rather 
than  to  await  the  quick  building  up  of  a  tendon  sheath.  The  bridge  of  soft 
parts  must  be  of  such  a  length  that  the  tendon  can  be  brought  in  a  direct 
line  to  its  new  point  of  insertion. 
The  diseased  tendon  need  not  be  di- 
vided. When  not  divided,  draw  the 
healthy  and  diseased  tendons  toward 
each  other,  by  means  of  instruments, 
and  make  a  buttonhole  in  the  dis- 
eased tendon  at  the   proper   place, 

into  which  the  transplanted  tendon        -r.       ^       .r,     ^ 

IT         1        4  (.,  1  n  Fig.  362. — Tendon  anastomosis :  tendon 

can  be  slipped.    Afterward  a  second  divided. 

similar  slit  could  be  made  nearer  the 

periphery,  so  as  to  make  a  true  braid.  Stitches  fix  the  tendons  at  the  situ- 
ations where  they  pass  through  slits  and  also  between  them.  When  divided 
they  are  joined  as  indicated  in  Fig.  362. 

The  Re  marls. — The  presence  of  atrophy  of  tendons  verifies  the  loss  of 
power  of  their  muscles  and  makes  the  diagnosis  sure. 

It  is  recommended  to  bring  the  end  of  the  muscle  bundle  in  sight,  which, 
if  it  presents  a  white,  pink,  or  dark  red  color,  would  indicate  paralysis,  pare- 
sis, or  a  normal  condition  respectively. 

In  order  to  avoid  tearing  out  of  the  tendons,  employ  a  strong  stitch, 
the  tendons  being  put  on  the  stretch. 

In  correcting  the  deformity  as  it  is  l)roug]it  into  nomial  and  even  over- 
corrected  position,  the  extremity  should  obey  light  pressure. 


346  OPERATIVE  SURGERY. 

If  the  transplantation  is  well  made,  one  should  be  able  to  recognize, 
while  the  patient  is  still  under  the  ansesthetic,  that  the  extremity  no  longer 
hangs  as  loosely  as  befoie,  and  no  longer  shows  the  strong  tendency  to  a 
faulty  position,  but  with  a  sure  elastic  tension,  remains  in  at  least  a  par- 
tially corrected  position.  Care  must  be  exercised  in  the  selection  of  a 
healthy  muscle,  the  tendon  of  which  is  to  be  joined  to  the  tendon  of  an  un- 
healthy one,  that  its  action  be  similar  in  nature  to  that  of  the  paralyzed 
muscle. 

The  Choice  of  Methods. — The  descending  transplantation  method,  if  pos- 
sible, as  well  where  the  whole  tendon  is  transplanted  [D)  as  where  it  is  par- 
tially transplanted  (/),  is  the  acceptable  method. 

After  eight  days  the  patient  is  allowed  to  get  up,  wearing  an  "  overshoe," 
and  in  all  wears  the  bandage  from  four  to  seven  weeks,  according  to  the  de- 
gree of  the  existing  deformity. 

The  after-treatment  consists  in  the  employment  of  massage,  gymnastics, 
baths,  electricity,  etc.,  and  the  more  faithfully  they  are  practiced  the  quicker 
and  more  perfect  is  the  recovery. 

The  Results. —  Vulpius  reports  twenty-one  tendon  transplantations  on 
nineteen  patients. 

One  case  completely  failed  as  a  result  of  suppuration  of  the  tendon  su- 
tures. • 

Two  cases  failed  on  account  of  very  extensive  paralysis  and  unsatisfac- 
tory technique. 

The  results  of  all  the  others  were  thoroughly  good  and  satisfactory  con- 
sidering the  individual  proportion  of  strength.  Sometimes  the  result  was  a 
perfect  one  beyond  expectation.  Furthermore,  it  was  shown  that  the  result 
not  only  was  lasting,  but  that  in  the  course  of  months  it  improved  still  more. 

Tabulated  Statement  of  Thirty-three  Cases  of  Tendon  Transplantation, 
with  Results  ( V^ulpius) : 

Results  good 20  cases. 

Results  good,  or  satisfactory,  but  not  perfect 4      " 

Improved 3      " 

Not  improved 2      " 

Doubtful  or  unknown  results 4      " 

Total 33      " 

Nicoladoni  grafted  the  peroneal  tendons  to  a  freshened  surface  of  the 
tendo  Achillis  to  restore  motion  to  a  paralyzed  calf.  Goldthwait  connected 
the  sartorius  muscle  with  the  fascia  over  the  rectus  femoris  and  vastus  in- 
ternus  portions  of  a  paralyzed  quadriceps  extensor.  An  active  extensor  of 
the  great  toe  can  be  caused  to  contribute  a  portion  of  its  vitality  to  a  power- 
less anterior  tibial  muscle  by  grafting.  Numerous  examples  illustrating  the 
idea  are  reported. 

Certainly  there  is  much  to  encourage  the  belief  that  substantial  benefit 
will  follow  the  practice.  The  aforegoing  figures  suggest  the  method  of  pro- 
cedure. Thorough  asepsis  and  strict  quietude  of  the  parts  should  be  en- 
forced until  union  has  taken  place. 


f 


OPERATIONS   ON  TENDONS,    LIGAMENTS,    FASCTAS,    ETC.  347 

Muscles  and  their  sheaths  are  ruptured  either  conjointly  or  separately 
from  the  elfects  of  miiscuhir  and  other  forms  of  violence.  Muscles  require 
division  to  overcome  deformities  incidental  to  their  contraction. 

Myotomy,  or  division  of  muscle,  is  performed  in  substantially  the  same 
manner,  and  for  similar  purposes  as  the  division  of  tendons.  The  liability 
to  ha?morrhage  is  greater  in  the  former,  on  account  of  the  greater 
vascularity  of  the  divided  tissues.  The  open  and  tJie  subcutaneous 
methods  of  division  can  be  employed,  the  latter  being  the  better. 
The  blade  of  the  myotome  should  be  long,  narrow,  and  blunt,  for 
obvious  reasons  (Fig.  3G3).  The  direction  of  the  division  in  my- 
otomy is  determined  by  the  demands  of  the  case.  The  transverse, 
oblique,  and  V-shaped  sections  are  the  ones  in  common  use.  If 
the  transverse  open  incision  be  made,  and  the  separation  of  the 
divided  extremities  be  extensive,  the  space  between  them  can  be 
bridged  with  numerous  catgut  sutures  connected  with  each  end 
of  the  divided  muscle.  The  sutures  and  the  blood  clots  entangled 
in  them  after  the  closure  of  the  wound  soon  lay  the  foundation  of 
repair  in  favorable  instances. 

Tlie  ohlique  division  of  a  muscle  consists  in  making  the  sec- 
tion of  the  entire  structure  in  an  oblique  direction  from  without, 
inward  and  downward,  or  vice  versa,  as  circumstances  dictate. 
The  length  and  the  degree  of  obliquity  will  be  regulated  by  the 
extent  of  the  shortening  of  the  muscle,  as  indicated  by  the  degree 
of  the  deformity  and  the  ability  to  correct  it  by  division  of  the  con- 
tracted muscle.  This  measure  is  practiced  best  through  an  open 
incision  made  parallel  with  but  not  in  line  of  the  proposed  mus- 
cular section,  for  if  thus  placed  the  cicatrix  of  the  skin  may  unite 
to  that  of  the  soft  parts  beneath  and  thus  crij^ple  the  muscular  ""^^ 
action.  After  oblique  division  and  rectification  of  the  deformity.  Myotome, 
the  divided  borders  are  stitched  together  with  fine  catgut.  If  the 
contraction  of  the  divided  muscle  be  so  pronounced  as  to  narrow  the  line 
of  repair  to  a  serious  degree,  the  muscle  can  be  supplemented  in  width  at 
this  situation  by  the  use  of  catgut  threads  employed  at  either  side  of  the 
muscle  in  the  manner  already  described.  The  external  wound  is  closed  care- 
fully, the  limb  bandaged  and  confined  in  a  fixed  position,  that  will  contrib- 
ute to  relaxation  of  the  severed  muscle. 

The  V-shaped  division  is  employed  frequently  in  connection  with  the 
broader  muscles  with  the  idea  of  rectifying  a  deformity  or  fortifying  a 
weak  point.  As  an  illustration  of  the  former  proposition,  the  quadriceps 
extensor  is  sometimes  thus  divided — after  the  necessary  separation  of  the 
vasti  portions — to  enable  one  to  approximate  properly  the  upper  and  lower 
fragments  of  an  old  fracture  of  the  patella  attended  with  otherwise  irredu- 
cible separation.  This  method  is  practiced  best  through  an  oval  flap  reach- 
ing down  to  the  quadriceps  itself.  The  length  and  obliquity  of  the  arms  of 
the  V  will  depend  on  the  degree  of  shortening  of  the  muscle,  i.  e.,  the  greater 
the  shortening,  the  greater  their  obliquity  and  length  should  be.  The  sliding 
of  a  portion  of  a  broad  muscle  by  the  agency  of  the  V-shaped  incision,  for 


348  OPERATIVE  SURGERY. 

the  purpose  of  strengthening  a  weakened  point,  as  of  the  abdominal  wall,  is 
a  measure  that  befits  the  repair  of  weakened  points  of  this  part  of  the  body. 
The  incision  should  be  so  placed  with  reference  to  the  direction  of  the  mus- 
cular fibers  as  to  comply  readily  with  the  demands  of  repair,  as  referable  to 
the  extent  of  the  sliding  and  the  magnitude  of  the  displaced  tissue.  In- 
cisions of  other  forms  than  those  already  cited  can  be  devised  for  the  pur- 
poses in  question. 

The  deltoid  ynuscle  can  be  divided  at  either  border,  at  the  central  part,  or 
through  its  entire  thickness  near  the  point  of  insertion,  depending  on  whether 
or  not  the  entire  muscle  or  isolated  portions  of  it  are  involved.  In  either  case 
the  muscle  is  relaxed,  the  myotome  inserted  beneath  the  fibers,  which  are 
divided  by  cutting  toward  the  surface.  The  blood  is  squeezed  out  of  the 
opening  on  withdrawal  of  the  blade,  as  in  tenotomy. 

The  pectoralis  major  can  be  divided  at  the  tendinous  insertion  or  further 
inward  at  the  axillary  fold.  In  either  instance  the  long,  blunt-bladed  teno- 
tome is  pressed  beneath  the  muscular  tissue,  and  the  division  is  made  toward 
the  surface. 

The  rupture  of  a  muscle  or  of  its  sheath  often  requires  active  surgical 
treatment,  especially  if  the  skin  be  involved.  In  the  former  injury,  with 
skin  involvement,  the  ruptured  ends  of  the  muscle  are  trimmed,  united 
with  catgut  sutures,  the  wound  is  closed  and  the  part  immovably  fixed  in 
such  a  position  as  to  relax  the  injured  muscle.  If  the  common  method 
of  introduction  of  sutures  into  the  borders  of  the  divided  muscle  be  not 
effective,  bundles  of  muscular  fibers  at  either  side  of  the  wound  may  be 
tied  separately  by  the  ligatures,  the  loose  ends  of  which  are  then  drawn  so  as 
to  bring  the  muscular  surfaces  together,  and  tied  the  same  as  in  tenorrhaphy 
(Fig.  347). 

If  the  sheath  he  ruptured,  the  rent  is  exposed  by  an  incision  made  at  the 
seat  of  the  injury.  The  muscular  fibers  are  pushed  back  into  the  sheath  and 
the  borders  of  the  rent  are  sewed  together  with  fine  silk  or  catgut.  The  re- 
maining dressing  is  the  same  as  for  the  rupture  of  a  muscle. 

Ligaments  not  infrequently  become  shortened,  elongated,  or  ruptured,  as 
the  result  of  disease  and  traumatism.  In  order  that  the  afflicted  part  may 
be  promptly  and  properly  restored  to  position,  the  ligaments  must  be  divided 
and  repaired  in  many  cases. 

Syndesmotomy  is  the  operation  of  the  division  of  ligaments  either  by  the 
subcutaneous  or  open  method,  the  latter  being  more  frequently  practiced. 
The  technique  of  this  procedure  will  appear  in  connection  with  operative 
treatment  of  deformities  of  the  foot,  since  it  is  most  frequently  employed  in 
that  class  of  cases.  The  best  illustration  of  elojigation  or  rupture  of  a  liga- 
ment is  seen  when  such  conditions  affect  the  Ugametitum  patellm.  If  elon- 
gated, it  can  be  shortened  in  the  same  manner  as  in  elongated  tendons 
elsewhere,  or  the  tuberosity  of  the  tibia  into  which  it  is  inserted  can  be 
displaced  downward  by  means  of  a  mallet  and  chisel,  and  fastened  to  the 
bone  with  nails  or  silver  wire.  If  ruptured,  a  free  incision  should  be  made 
down  to  the  rend  in  the  long  axis  of  the  ligament,  the  extremities  united 
together  with  kangaroo  tendon,  catgut,  or  silk,  the  wound  closed  and  the 


OPERATIONS  ON  TENDONS,   LIGAMENTS,   FASCIAS,   ETC.         3i9 

limb  slightly  eleviited  and  confined  firmly  in  the  extended  position  for  three 
or  four  weeks.  If  the  tendon  be  so  much  damaged  as  not  to  permit  proper 
apposition  of  the  ends,  the  catgut  bridging  employed  for  the  repair  of  the 
tendons  can  be  utilized.  Another  plan  is  to  displace  upward  the  tubercle 
of  the  tibia  with  the  mallet  and  chisel,  and  fasten  it  in  the  new  position  with 
small  nails  or  silver  wire.  But  little  advantage,  however,  can  follow  this 
step  on  account  of  the  limited  bone  surface  above.  Moreover,  necrosis  of 
the  fragment  may  ensue  for  this  reason.  Our  experience  in  this  measure  is 
not  flattering.  The  part  should  then  be  dressed  antiseptically  and  otherwise 
treated  as  for  fracture  of  the  patella. 

Fascia. — Although  the  entire  body  is  wrapped  in  fascia,  it  is  only  to 
certain  parts,  as  the  palm  of  the  hand,  the  sole  of  the  foot,  and  to  the 
fascia  lata,  that  special  attention  is  directed,  on  account  of  morbid  mani- 
festations. 

The  2)lantar  fascia  is  an  exceedingly  dense,  white  fibrous  membrane  of 
great  strength,  with  the  fibers  arranged  longitudinally.  It  is  divided  into 
three  portions,  the  middle  and  two  lateral.  The  former  is  the  one 
especially  concerned  in  those  deformities  requiring  division.  It  is 
narrow  behind  and  attached  to  the  inner  tubercle  of  the  os  calcis ; 
broader  and  thinner  in  front,  and  divides  into  five  processes  oppo- 
site the  middle  of  the  metatarsal  bones,  there  being  one  for  each 
of  the  toes.  Each  of  these  processes  divides  opposite  the  metatarso- 
phalangeal articulations  into  two  slips,  which  embrace  and  are  in- 
serted into  the  sides  of  the  flexor  tendons,  blending  with  their 
sheaths  and  with  the  transverse  metatarsal  ligament.  It  likewise 
sends  prolongations  between  the  groups  of  the  plantar  muscles. 
This  fascia  serves  the  important  function  of  assisting  in  main- 
taining the  integrity  of  the  plantar  arch.  It  is  frequently  con- 
tracted in  deformities  of  the  foot,  and  requires  division  to  accom- 
plish a  cure. 

The  Operation  of  Plantar  Fasciotomy. — Extend  the  foot  firm- 
ly, thus  placing  the  fascia  on  the  stretch.  "  Point  pressure  "  is 
then  made  to  establish  the  proper  seat  for  division.  Introduce 
beneath  the  inner  border  of  the  fascia  at  the  point  of  greatest 
pressure-irritation  a  long-bladed,  sharp-pointed  fasciatome  (Fig. 
364),  turn  the  edge  toward  the  sole  and  cut  through  the  fascia  to 
the  integument.  If  the  foot  is  vigorously  extended  at  this  time, 
the  last  fibers  of  the  fascia  will  be  ruptured.  Press  out  the  blood, 
close  the  opening  with  a  suture  or  an  antiseptic  pad,  rectify  the  ^ig.  364. 
deformity,  and  confine  the  foot  in  proper  position  (Fig.  342)  tome, 
until  the  wound  is  healed.  The  internal  plantar  artery  should  be 
avoided  by  keeping  the  lilade  close  to  the  inner  border  and  deep  surface 
of  the  fascia.  The  division  of  the  bands  at  the  phalangeal  junction  must 
be  carefully  made,  or  the  digital  arteries  and  nerves  will  be  severed.  Care 
should  be  practiced  in  overcoming  a  pronounced  deformity,  or  rupture  of 
the  digital  nerves  will  happen.  Kelapse  sometimes  follows  this  method  of 
treatment. 


350 


OPERATIVE  SURGERY. 


The  Palmar  Fascia. — The  palmar,  like  the  plantar  fascia,  is  divided  into 
three  portions,  the  middle  being  of  special  significance.  This  portion  is 
narrow  above  and  is  connected  to  the  lower  border  of  the  annular  ligament ; 
below  it  is  broader  and  thinner,  and  opposite  the  heads  of  the  metacarpal 
bones  divides  into  four  slips,  one  for  each  finger.  Each  slip  subsequently 
divides  into  two  processes,  which  inclose  the  tendons  of  the  flexor  mus- 
cles, and  are  attached  to  the  glenoid  ligament  and  to  the  sides  of  the  meta- 


DIGITAL  ARTERY: 
DIGITAL  nerve:: 


EXTENSOR  METACARPI ANO 
EXTENSOR  BREVIS  POULICIS^. 


FLEXOR  LOHSU3POLUCIS. 


Fig.  365. — Palmar  fascia. 

carpal  bones,  and  extend  upward  over  the  flexor  tendons  nearly  to  the  tips 
of  the  flngers  (Fig.  365).  This  fascia  is  intimately  connected  with  the  in- 
tegument of  the  palm,  and  sends  vertical  septa  between  its  muscles.  From 
various  causes  it  may  undergo  structural  changes  which  result  in  contrac- 
tions of  the  fingers  on  the  palm,  as  well  as  shortening  of  the  palm  itself. 
The  anatomical  arrangement  of  the  fascia  fully  explains  the  mechanism  of 
these  deformities. 


OPERATIONS  ON  TENDONS,  LIGAMENTS,  FASCIAS,  ETC. 


351 


Pig.  366. — Fascial  contractions. 
Fascial  contractions,     b.  Flexor  tendons. 


Dupuytren's  Contraction. — This  deformity  depends  upon  the  contraction 
of  the  elongations  of  fascia  of  the  palm, connected  with  the  digits  (Fig.  366)  ; 
the  morbid  process 
more  frequently  man- 
ifests itself  in  the 
ring  and  little  fin- 
gers, of  ttimes  causing 
them  to  become  oj)- 
posed  to  the  palmar 
surface  of  the  hand. 
The  Fallacy. — 
This  deformity  may 
be  confounded  with 
that  dependent  upon 

contraction  of  the  flexor  tendons.    An  examination  of  Fig.  366  will  enable 
the  surgeon  to  make  a  clear  distinction  between  the  two  conditions. 

Adams's  Method. — Anaesthetize  the  patient,  render  the  constricting 
bands  tense  by  a  firm  extension  of  the  affected  digits,  and  then,  under  anti- 
septic precautions,  divide  the  restraining  bands 
at  short  intervals,  subcutaneously  (Fig.  367),  at 
unattached  points  of  the  skin,  with  a  sharp- 
pointed,  narrow-bladed,  strong,  short  fasciatome 
(Fig.  368),  the  edge  being  directed  from  the 
surface  of  the  palm.  When  sufficiently  liberated 
the  digits  can  be  freely  extended,  in  which  con- 
dition they  are  to  be  confined  by  dorsal  splints 
until  repair  is  completed.  Passive  motion  and 
forcible  extension  until  the  tendency  to  contrac- 
tion is  overcome,  comprise  the  impor- 
tant elements  of  the  after-treatment. 
The  outcome  is  often  unsatisfactory. 

The  Results. — Relapse  not  infre- 
quently takes  place  owing  to  the  con- 
tinued presence  of  the  primary  cause 
and  the  inheritance  by  the  new  tissue 
of  the  characteristics  of  the  old. 

Goyraud's  Method. — Goyraud  made 
longitudinal  incisions  over  the  tense 
digital  elongations  of  the  fascia,  dissected  the  integument  from 
them,  after  which  they  were  divided  transversely  sufficiently  to 
permit  extension  of  the  digits.  He  closed  the  integumentary  in- 
cisions and  confined  the  fingers  in  a  straight  position  until  healed. 
The  success  of  this  method  is  gratifying. 

Hardie's  Modification  of  Goyraud's  Method. — Apply  an  elastic 
bandage  to  the  hand,  make  an  incision  from  half  an  inch  above  the 
principal  transverse  fold  of  the  palm  to  beyond  the  bone  of  the  last 
phalanx  involved  down  to  the  band,  and  carefully  expose  the  con- 


FiG.  367. — Transverse  inci 
sions  in  Dupuytren's  con 
traction. 


Fig.  368. 

Strong, 
short 
fascia- 
tome. 


352  OPERATIVE  SURGERY. 

tracted  tissue  ;  sever  the  bands  at  the  webs  of  the  fingers  between  this  and 
the  adjacent  contracted  elongations ;  divide  the  main  bundle  at  the  upper 
end  of  the  incision  and  completely  extend  the  phalanx.  If  required,  make 
transverse  incisions  opposite  the  bundle  of  the  first  and  second  phalanges, 
cut  away  portions  of  fascia  that  oppose  complete  extension  of  the  finger, 
and  remove  entirely  isolated  projecting  portions  of  fascia.  Treat  likewise 
the  remaining  fingers  of  the  hand  similarly  deformed,  remove  the  bandage, 
tie  briskly  bleeding  points,  drain  the  wound  the  entire  length  with  horse- 
hair, close  the  incision  with  silver  wire,  apply  an  antiseptic  pad  to  the  palm 
and  a  straight  splint  to  the  fingers,  and  bandage  both  in  position.  The 
dressing  is  renewed  on  the  following  day,  again  applied,  and  not  disturbed 
for  a  week  without  special  reason.  The  use  of  the  splint  is  continued  for 
two  or  three  weeks  and  the  fingers  are  occasionally  flexed  and  extended. 
Treves  omits  the  elastic  bandage  and  drainage  and  closes  the  wound  with 
silkworm  gut.  He  excises  as  much  of  the  contracted  fascia  as  can  safely 
be  removed,  causes  the  splint  to  be  worn  for  a  month,  after  which  massage 
of  the  palm  and  passive  motion  of  the  fingers  is  practiced  until  a  satisfactory 
result  is  obtained. 

The  Remarks. — Complete  antiseptic  technique  should  be  practiced,  as  the 
wound  is  severe  and  exposes  the  patient  to  the  danger  of  extensive  and  destruc- 
tive inflammation  of  the  hand.  Eadical  measures  are  the  better,  and  expose 
the  patient  to  no  unusual  dangers  when  practiced  with  thorough  antisepsis. 
Adams's  method  can  be  done  well  with  cocaine  anaesthesia  in  many  instances. 

The  fascia  in  other  situations  may  become  contracted,  as  the  fascia  lata 
at  its  upper  or  lower  extremities.  Whenever  these  contractions  cause  a  per- 
sistent deformity  they  should  be  divided,  and  upon  the  same  principles  as 
like  tissues  in  other  portions  of  the  body. 

BurssB. — The  synovial  and  mucous  bursas  are  each  liable  to  annoying 
enlargements,  the  result  of  chronic  and  acute  inflammatory  processes  of  trau- 
matic or  idiopathic  origin.  The  enlargements  communicate  so  frequently 
with  the  general  synovial  cavity  of  a  contiguous  joint  that  they  should  be 
approached  with  great  care  and  strict  antisepsis.  The  characteristic  patho- 
logical manifestations  of  this  variety  of  infliction  occur  in  connection  with 
the  synovial  sacs  of  the  carpus  and  the  tendinous  sheaths  of  the  tendons  of 
the  wrist,  and  are  known  respectively  as  ganglion  and  chronic  thecitis,  the 
latter  being  usually  of  tuberculous  origin. 

Ganglion  (Weeping  Sinew). — Glanglion  is  developed  on  the  dorsal  surface 
of  the  carpus  and  is  connected  with  the  sheath  of  a  tendon  at  this  situation 
or  with  the  synovial  sac  of  a  carpal  articulation. 

The  Operative  Methods  of  Cure  of  Ganglion. — After  the  failure  of  sim- 
pler methods  of  relief  the  sac  of  the  tumor  may  be  ruptured  by  a  sudden 
pressure  of  the  thumb,  by  a  sharp  blow  from  the  back  of  a  book,  or  a  similar 
agent.  These  measures  cause  rupture  of  the  sac  and  the  escape  into  the  con- 
nective tissue  of  the  contents,  which  are  subsequently  absorbed.  However, 
they  frequently  recur  when  thus  treated.  Another  simple  and  quite  effective 
means  of  cure  is  the  injection  into  the  sac,  after  withdrawal  of  a  portion  of 
the  fluid  by  a  hypodermatic  syringe,  of  a  few  drops  of  a  five-  or  ten-per-cent 


OPERATIONS  ON  TENDONS,   LIGAMENTS,   PASCIAS,   ETC.  353 

solution  of  carbolic  acid  and  glycerin.  Not  infrequently  in  this  instance  a 
quite  severe  inflammation  follows  the  injection.  Therefore,  after  the  injec- 
tion the  hand  should  be  kept  quiet,  and,  if  indicated,  cold  lotions  are  applied 
to  the  part.  If  the  sac  be  so  tough  as  to  withstand  the  force  used  for  the 
purpose  of  rupture,  it  may  be  incised  subcutaneously  and  under  strict  anti- 
septic precautions  with  a  small,  sharp-pointed  tenotome.  The  fluid,  when 
thus  liberated,  escapes  into  the  connective  tissue  and  is  absorbed  as  in  the 
first  Instance.  Finally,  if  the  tumor  be  very  large  or  hard,  or  have  resisted 
the  simpler  methods  of  cure,  a  free  incision  is  made  down  upon  it,  and  the 
sac  is  dissected  from  the  tendon  or  cut  away  from  the  synovial  membrane  of 
the  articulation.  In  the  latter  case  a  sufficient  amount  of  the  membrane 
should  remain  behind  to  permit  of  the  sewing  together  of  the  borders  with 
fine  catgut  or  silk,  thus  closing  the  cavity  of  the  joint.  In  every  instance  of 
free  incision  a  strict  antiseptic  technique  should  be  enjoined  for  obvious  rea- 
sons. In  the  synovial  bursae  associated  with  other  and  larger  joints  of  the 
body,  attempts  at  cure  by  aspiration  and  the  injection  of  antiseptic  stimulat- 
ing fluids  should  be  made  before  free  incision  is  practiced.  And  in  the  lat- 
ter instances  great  care  must  be  exercised  to  avoid  the  disastrous  results 
incident  to  unwise  aggression  and  faulty  technique. 

Mucous  BurscB. — Mucous  bursse  are  situated  between  the  integument  and 
subcutaneous  bony  prominences  at  situations  exposed  to  friction  or  pressure. 
Those  located  over  the  patella  and  olecranon  process  are  the  best  illustra- 
tions of  the  variety,  and  will  suffice  for  the  proper  consideration  of  the  mor- 
bid processes  of  this  class  of  bursae. 

Prepatellar  Bursitis  (Housemaid's  Knee). — Aspiration,  tapping,  and  in- 
jection, the  seton  or  incision,  are  the  methods  of  cure  applied  to  this  disease. 
Aspiration  is  simple  and  inefficient ;  tapping  and  injection  are  frequently 
successful ;  the  seton  is  beneficial  though  troublesome  ;  incision  is  the  surest 
of  all  means  of  cure.  The  withdrawal  of  a  portion  of  the  fluid,  and  the  in- 
jection of  a  small  amount  of  a  solution  of  carbolic  acid  and  glycerin,  is  fre- 
quently followed  by  cure.  The  patient  should  be  kept  quiet  for  two  or 
three  days,  and  cold  lotions  applied  to  the  part  when  essential  to  comfort. 
The  introduction  through  the  tumor  of  one  or  two  silken  threads  saturated 
with  stimulating  fluids,  such  as  the  compound  tincture  of  iodine,  solutions 
of  carbolic  acid,  etc.,  frequently  lead  to  satisfactory  results.  This  jjlan  is, 
however,  often  annoying  and  protracted,  on  account  of  the  discharge  and 
tardy  therapeutical  action.  Free  incision  and  packing  with  gauze  after 
scraping  the  cavity  is  the  surest  plan  of  cure.  The  incision  can  be  made  at 
one  or  both  sides  of  the  tumor  at  the  most  dependent  part,  as  may  seem  the 
best.  The  making  of  a  straight  or  crucial  incision  at  the  summit  of  the 
tumor  is  sometimes  practiced  in  order  to  reach  the  remotest  limits  of  the 
sac,  which  can  be  dissected  out  if  deemed  advisable.  However,  this  plan 
localizes  not  infrequently  a  sensitive  scar  at  the  point  of  common  pressure. 
If  the  sac  be  dissected  away,  close  apposition  of  the  divided  borders  can  be 
secured,  and  prompt  union  and  rapid  recovery  will  follow.  If  the  sac  re- 
main in  situ  the  wound  is  usually  packed  with  antiseptic  gauze,  and  per- 
mitted to  heal  slowly  from  the  bottom. 


354 


OPERATIVE  SURGERY. 


Post-olecranon  Bursitis  (Miner's  Elbow). — Bursitis  at  this  location  can 
be  cured  by  either  of  the  methods  directed  to  the  relief  of  the  prepatellar 
variety.  In  this  instance,  however,  the  dissection  of  the  sac  from  its  en- 
vironments must  be  carefully  done,  or  the  joint  cavity  will  be  invaded,  or 
the  tendon  of  the  triceps  impaired. 

Thecitis. — Thecitis  is  an  obstinate  and  troublesome  affection  usually  of 
the  synovial  sheaths  of  the  flexor  and  extensor  tendons  of  the  carpus,  char- 
acterized by  a  fluctuating  deformity  dependent  on  the  presence  in  the  di- 
lated sheaths  of  a  fluid  of  varying  character  and  consistency,  and  often  con- 
taining the  so-called  rice  or  melon-seed  concretions  of  fibrin.  Tubercle 
bacilli,  too,  are  frequently  present  in  these  cases.  The  extent  and  com- 
municability  of  the  sheaths  of  the  flexor  tendons  are  well  exhibited  in  Fig. 

369.  Operative  treatment  holds 
out  the  only  reasonable  hope  of 
cure  in  these  cases.  Tapping  and 
injection^  evacuation  and  scrap- 
ing^ and  excision  are  the  opera- 
tive measures  employed.  Tapping 
and  the  injection  of  curative  fluids 
require  but  brief  mention  here, 
as  their  therapeutic  efficacy  and 
practical  technique  are  properly 
measured  by  a  like  treatment  of 
similar  conditions  elsewhere  in  the 
body.  The  introduction  into  the 
sac  of  a  mixture  of  iodoform  and 
glycerin  is  regarded  by  some  ob- 
servers as  having  a  special  virtue. 
Tlie  operation  of  evacuation 
and  scraping  contemplates  a  free 
incision  into  the  tumor  at  the 
most  commanding  point,  and  a 
thorough  scraping  of  the  sheaths  of 
the  tendons  with  properly  shaped 
curettes  and  scoops.  The  strict- 
est antiseptic  surveillance  must  be 
practiced,  or  serious  inflammatory  results  will  follow.  The  wound  should 
be  closed  with  silkworm  gut  and  covered  with  firmly  applied  pads  of  anti- 
septic gauze  combined  with  sponge  pressure.  Then  the  wrist  joint  is  immov- 
ably fixed  until  inflammatory  reaction  is  in  abeyance,  after  which  the  fingers 
are  frequently  though  carefully  manipulated. 

Excision. — Excision  offers  the  best  means  of  cure,  especially  if  the  fibrous 
connections  and  tuberculous  infection  be  present. 

The  Operation. — Apply  an  elastic  bandage  to  the  hand  and  forearm,  make 
a  free  incision  into  the  tumor,  and,  if  necessary  to  reach  the  disease,  through 
the  annular  ligament  as  well.  Carefully  and  patiently  dissect  away  and  re- 
move all  diseased  structure,  harming  as  little  as  possible  the  contiguous 


Fig.  369. — Tendinous  sheaths  of  digits,  palm, 
and  wrist. 


OPERATIONS  ON   TENDONS,  LIGAMENTS,  FASCIAS,    ETC.  355 

healthy  tissues.  If  a  portion  of  a  tendon  be  involved,  the  diseased  part 
should  be  excised  and  the  tendon  repaired.  The  ligaments,  fascia,  and  in- 
tegument are  each  united  independently  with  fine  catgut  or  silk  sutures, 
leaving  a  small  opening  at  either  end.  An  antiseptic  compress  is  uniformly 
and  firmly  applied  to  the  wound,  and  the  extremity  immovably  fixed  with  a 
splint.  This  dressing  need  not  be  renewed  for  a  week  or  ten  days,  except 
for  some  special  reason.  After  the  first  forty-eight  hours  the  patient  is 
directed  to  move  the  fingers  actively  at  intervals  until  repair  is  established, 
in  order  that  the  new  tendinous  tissue  may  become  suitably  fitted  for  use. 
Eelapses  of  the  disease  may  occur,  and  in  fact  the  patient  may  succumb  to 
tuberculous  involvement  of  remoter  and  more  important  parts. 

Acute  Thecitis  or  Tenosynovitis. — It  is  very  important  to  note  in  con- 
nection with  this,  so  often  functionally  disastrous  inflammation  of  the 
hand,  the  relations  which  its  tendinous  sheaths  bear  to  each  other;  for  an 
infected  little  finger  is  often  followed  by  rapid  involvement  of  the  palm, 
causing  a  destructive  palmar  abscess.  Again,  infection  of  the  palm  inflicts 
the  little  finger,  but  not  usually  the  ring,  middle,  and  index  fingers,  for 
apparent  anatomical  reasons  (Fig.  369).  For  like  reasons  the  thumb  only 
may  become  involved  from  above,  or  it  may,  when  infected,  lead  to  extensive 
invasion  of  the  forearm  without  much  palmar  complication. 

The  Treatment. — Prompt  and  free  incisions  of  only  the  regions  invaded, 
attended  with  thorough  cleansing  and  perhaps  removal  of  infected  mem- 
branes, should  be  practiced,  followed  by  careful  drainage  and  aseptic  dress- 
ing. Later,  passive  motion,  massage,  etc.,  should  be  patiently  and  persist- 
ently employed. 


CHAPTEE  VIII. 

OPERATIONS  ON  BONUS. 

The  injuries  and  diseases  to  whieh  bones  are  liable,  although  not  differ- 
ing in  any  essential  particular  from  similar  conditions  of  the  soft  parts,  re- 
quire an  independent  consideration  on  account  of  the  difference  in  function 
and  structure  of  the  osseous  system.  The  integument  and  soft  parts  gen- 
erally are  each  the  seat  of  inflammation,  ulceration,  and  gangrene.  Bony 
tissue  is  likewise  afflicted  by  the  same  morbid  processes,  named,  however, 
differently :  caries  of  bone  being  comparable  to  ulceration  of  the  soft  parts, 
while  necrosis  of  bone  finds  its  synonym  in  gangrene  of  soft  parts.  The 
unimpaired  preservation  of  the  mechanical  functions  of  tissues  is  the  great 
aim  in  surgery.  Therefore  since  the  practical  functions  of  bones  are  to  sup- 
port the  body,  protect  important  organs,  and  serve  as  levers  for  purposes  of 
prehension  and  locomotion,  one  has  but  to  act  with  a  knowledge  of  these 
facts  and  of  the  methods  to  maintain  them,  to  give  to  the  patient  the  full 
benefit  of  our  art. 

The  operations  upon  bone  are  denominated  gouging,  sequestrotomy,  ex- 
cision, osteotomy,  and  osteoplasty. 

Gouging. — Gouging  is  applied  to  the  removal  of  carious  bone,  and  should 
not  be  attempted  until  the  process  has  become  chronic  (Fig.  370). 

The  Operation. — Having  arranged  the  patient  in  a  position  suitable  for 
the  convenience  of  the  operator,  administer  an  anaesthetic,  apply  the  elastic 
bandage  if  practicable,  carrying  it  lightly  over  the  site  of  the  disease,  locate 
the  diseased  bone  with  a  probe,  make  a  free  incision  down  upon  it,  sepa- 
rate the  soft  parts  with  retractors,  then  with  the  gouge,  bone  burr,  etc.,  re- 
move the  diseased  structure. 

The  Comments. — Dependent  drainage  and  scrupulous  care  in  the  separa- 
tion of  muscular  structure  without  needless  bruising  of  the  tissues  should 
always  be  practiced.  It  is  important  and  often  very  difficult  to  determine 
the  line  between  the  healthy  and  diseased  bone.  If  the  portions  removed 
when  washed  present  a  whitish,  grayish,  or  blackish  appearance,  and  are 
porous  and  fragile  instead  of  being  vascular,  red,  and  tough,  the  operation 
should  be  continued.  If  the  gouged  surfaces  bleed  freely  from  numerous 
points  and  have  a  normal  firmness  and  color,  the  operation  should  cease. 

It  is  important  in  gouging  the  extremities  of  bones  to  use  extreme  cau- 
tion or  the  joint  cavities  may  be  opened  directly  or  become  secondarily  in- 
volved. 

356 


OPERATIONS  ON   BONES. 


357 


After  the  removal  of  the  elastic  constriction  all  haemorrhage  should  be 
arrested,  the  wound  washed  thoroughly  with  a  suitable  antiseptic  solution, 
good  drainage  secured,  the  soft  jiarts  united,  and  dressed  antiseptically. 

It  frequently  happens  in  these  cases  that  a  cavity  in  the  bone  of  consid- 
erable size  results  from  the  operation.     If  the  diseased  tissue  of  both  the 


MM 


Fig.  370. — Instruments  employed  in  gouging. 
a,    b.    Strong   scalpels,     c,   e.    Retractors,     d.    Barker's   douching   scoop.    /,  g.   Scoops. 
h,  i,   k.   Mallet   and   gouges.     I.   Sponge   holder,    m.    Bone   burr.     Forcipressure, 
sutures,  needles,  drainage  agents,  etc.,  are  likewise  needed. 
25 


358 


OPERATIVE  SURGERY. 


hard  and  soft  parts  can  be  removed^  and  there  be  no  sinus  communications 
with  other  diseased  areas,  an  attempt  should  be  made  to  repair  the  defect 
promptly  by  a  method  of  healing  devised  hy  Schede  (Fig.  371).  In  this  pro- 


FiG.  371.— Schede's  method. 
Diagram  showing  relations  of  organizing  blood  clot. 

cedure  the  soft  parts  are  not  closed  until  the  oozing  of  blood  from  the  bone  is 
nearly  arrested  or  only  sufficiently  active  to  be  arrested  by  closure  of  the  soft 
parts,  thus  leaving  the  cavity  filled  but  not  distended  with  blood.  The  wound 
of  the  soft  parts  is  then  closely  united  with  fine  aseptic  catgut  or  silkworm 
gut,  and  the  surface  covered  widely  with  a  layer  of  aseptic  rubber  tissue, 
which  is  bound  firmly  in  place  with  antiseptic  gauze.  Additional  dressings 
are  applied  in  the  usual  manner,  confined  in  place,  and  the  part  is  kept  quiet. 
If  the  effort  fail,  local  evidences  of  deep-seated  inflammation  will  be  manifest 
when  the  dressings  are  removed  a  few  days  later,  and  the  lips  of  the  wound 
should  then  be  separated  by  the  surgeon,  the  cavity  cleaned  out,  and  per- 


FiG.  372. — Neuber's  method. 
Top  of  involucrum  removed,  skin-fiaps  turned  into  the  bottom  of  the  bone  cavity. 

mitted  to  heal  from  the  bottom.  The  canalization  method  of  Neuber  may 
be  employed  instead  of  Schede's  plan  of  repair  (page  107). 

Sequestrotomy. — Sequestrotomy  is  employed  for  removal  of  dead  bone 
en  masse,  and  is  therefore  applicable  to  the  treatment  of  necrosis.  Two 
methods  of  procedure  are  employed,  depending  on  the  nature  of  the  case 
— viz.,  the  direct  and  indirect  methods  (Fig.  374). 

The  Operation  hy  the  Direct  Method. — Having  determined  the  situation 
of  the  necrosed  bone,  and  being  satisfied  either  from  the  long  course  of  the 


OPERATIONS  ON  BONES. 


359 


disease,  or  by  movement  of  the  dead  portion,  that  detachment  of  the  dead 
from  the  living  bone  has  taken  phice,  apply  tlie  elastic  bandage  if  expedient, 
using  care  not  to  force  deleterious  matters  into  the  circulation,  select  a  strong 
scalpel,  and  connect  the  fistulous  openings  with  each  other  down  to  the  bone 
with  the  aid  of  a  grooved  director  or  a  probe,  choosing  such  openings  as 


Fig.  373. — Diagram  of  a  transverse  section,  showing  relations  of  sequestrum,  involuerum, 

fistula,  and  skin. 

will  cause  the  connecting  incision  to  be  consistent  with  good  drainage,  easy 
access  to  the  diseased  parts,  safety  to  the  underlying  structures,  and  a  mini- 
mum disfigurement.  Separate  the  borders  of  the  incision  with  retractors  so 
as  to  fully  expose  the  openings  in  the  involuerum.  If  the  sequestrum  can  be 
drawn  out  of  the  opening  with  suitable  forceps  (Fig.  374,  d)  it  should  be 
done  carefully,  otherwise  the  reparative  tissue  upon  which  it  rests  will  be  in- 
jured and  the  process  of  recovery  delayed.  If  it  be  too  large  or  interlocked 
with  healthy  bone,  the  opening  must  be  increased  sufficiently  to  admit  of  its 
withdrawal;  or,  if  this  be  impracticable,  another  incision  should  be  made 
corresponding  to  the  long  axis  of  the  sequestrum.  The  periosteum  should 
be  carefully  raised  on  either  side  of  the  incision,  to  permit  the  application  of 
a  crown  trephine  (i)  to  the  involuerum,  with  which  it  should  be  perforated  a 
sufficient  number  of  times  to  permit  of  the  easy  removal  of  the  dead  por- 
tion either  with  or  without  chiseling  (k)  away  the  irregular  bony  borders. 

The  gnawing  forceps  (c),  chisels,  and  saws  (/,  g,  i)  may  be  used  in  lieu 
of  or  in  conjunction  with  the  trephine  for  removal  of  the  sequestrum. 

If  there  be  but  one  sinus  opening,  and  evidences  of  disease  exist  above  or 
below  it,  the  center  of  the  incision  should  correspond  to  the  course  of  the 
sinus  if  the  anatomical  relations  will  permit. 

The  Precautions. — It  is  necessaryin  making  these  incisions  in  the  vicinity 
of  joints  to  exercise  great  care  to  avoid  opening  contiguous  synovial  pouches. 
It  therefore  follows  that  the  anatomy  of  the  joint  under  consideration 
ought  to  be  well  understood,  not  only  with  the  idea  of  locating  the  sites 
of  the  bursse  associated  with  it,  but  also  the  common  and  exceptional  rela- 
tions of  these  bursas  with  each  other.  A  bursa  communicating  with  a 
joint  indirectly  by  means  of  an  intervening  bursa  may  be  more  dangerous 
than  one  with  a  direct  communication;  as,  in  the  latter  instance,  a  knowl- 
edge of  the  fact  obviates  all  peril,  while  in  the  former,  ignorance  of  the 
possibility  of  communication  might  so  relax  the  vigilance  of  the  operator 
as  to  beget  disaster.  The  writer  has  in  mind  an  instance  of  this  kind. 
Flexion  of  the  limb  at  the  joint  in  question  usually  reduces  to  a  minimum 
the  area  of  exposure  to  operative  injury  the  synovial  elongations  of  the  joint. 


360 


OPERATIVE  SURGERY. 


Fig.  374. — Instruments  employed  in  sequestrotomy. 
a,  a'.  Strong  scalpels  and  probe,  b.  Retractors,  c.  Bone-cutting  forceps  and  rongeur 
d.  Sequestrum  forceps,  e.  Mallet.  /,  g,  I.  Lifting  back,  keyhole,  and  Gigli-Haertei 
saws.  h.  Scoop,  i.  Large  and  small  crown  trephines.  /.  Periosteotome  J'  k 
Gouges  and  chisels.  Gro  )ved  director,  bone  elevator  (Fig.  236,  k),  forci pressure' 
ligatures,  sutures,  needles,  drainage  agents,  etc.,  are  required.  ' 


OPERATIONS  ON  BONES.  361 

When  the  portion  of  bone  removed  is  large,  or  the  remaining  part  is 
small  and  fragile,  the  limb  must  be  supported  l\y  a  splint,  otherwise  the  bone 
may  bend  or  break  and  thereby  modify  unfavoraljly  the  ultimate  result. 

If  the  sequestrum  be  not  wholly  separated  from  the  healthy  bone  it 
should  be  allowed  to  remain  in  part  until  the  process  of  separation  is  com- 
pleted, then  it  can  be  removed. 

After  tlie  removal  of  the  dead  bone  the  cavity  throughout  its  whole  extent 
should  be  thoroughly  scraped  and  cleansed,  and  suitable  drainage  provided. 
The  soft  parts  should  then  be  closed  and  an  antiseptic  dressing  applied. 

Suhperiosteal  removal  of  healthy  and  of  injured  bone  will  be  noted  fur- 
ther along,  when  requirements  demand,  for  special  purposes. 

The  Indirect  Method. — The  indirect  method  is  preferable  when  the  bone 
is  superficial  and  the  disease  progressive,  as  in  osteitis  of  the  lower  jaw,  clav- 
icle, bones  of  the  arm,  forearm,  or  tibia ;  in  fact  all  the  long  and  many  of 
the  flat  bones  can  be  reproduced  by  this  method.  The  indirect  method  con- 
sists in  making  a  free  incision  through  the  periosteum  down  upon  the  dis- 
eased bone  and  separating  the  former  by  means  of  the  handle  of  a  scalpel, 
spatula,  or  periosteal  elevator.  The  separation  must  be  renewed  at  intervals 
and  each  time  not  extend  beyond  the  diseased  portion  of  bone.  The  length 
of  the  intervals  will  depend  upon  the  activity  of  the  morbid  process  and 
the  rapidity  of  bone  reproduction.  This  plan  is  necessarily  tedious  both  in 
detail  and  in  time,  but,  sooner  or  later,  the  dead  bone  can  be  raised  from  its 
new  osseous  trough,  which  will  soon  become  filled  with  new  bone  that  rarely 
fails  to  serve  the  purposes  of  its  predecessor.  The  free  incision  necessary  to 
expose  the  dying  bone  will  provide  good  drainage.  The  wound  is  kept  clean 
by  ordinary  antiseptic  means.    This  is  sometimes  called  subperiosteal. 

Excision. — Excision  of  bone  is  a  conservative  measure  directed  to  the 
extraction  of  such  portions  of  bone  as  are  inconsistent  with  future  useful- 
ness or  the  symmetry  of  the  part,  together  with  the  removal  of  the  diseased 
condition  calling  for  operation.  Excision  is  often  employed  in  lieu  of  the 
more  radical  measure — amputation.  It  is  practiced  at  the  articular  ex- 
tremities or  the  shaft  of  a  bone,  and  in  either  instance  it  may  be  a  partial 
or  complete  excision.  The  articular  extremities  or  joints  are  excised  on  ac- 
count of  injury,  disease,  or  ankylosis  in  a  faulty  position. 

The  General  Remarks. — In  estimating  the  prognosis  as  to  life,  the  sur- 
roundings of  the  patient,  the  previous  habits,  present  conditions,  and  the 
existence  of  constitutional  taint  must  be  considered,  also  the  nature  and 
extent  of  the  cause  demanding  operative  procedure.  The  prospective  use- 
fulness of  the  limb  will  depend  on  tbe  ability  of  the  surgeon  to  leave  the 
muscular  attachments  intact,  and  also  upon  the  condition  of  the  nerves  that 
animate  and  the  blood  vessels  that  nourish  the  structures.  If  the  patient 
be  a  manual  laborer,  or  one  oversensitive  of  deformity,  it  is  well  to  consider 
whether  additional  advantages  can  be  derived  from  artificial  limbs  and  ap- 
pliances, and  if  so  it  may  be  deemed  wiser  to  sacrifice  the  offending  member 
by  amputation.  The  incisions  for  the  necessary  exposure  of  the  parts  to  be 
removed  should  be  free,  and,  when  possible,  made  in  the  long  axis  of  the 
bone.     They  are  often,  however,  varied  to  suit  the  peculiar  demands  of  the 


362  OPERATIVE  SURGERY. 

individual  cases.  They  are  likewise  varied  in  the  different  joints,  being  in 
one  instance  longitudinal,  in  another  TJ-,  H-,  or  V-shaped,  according  to  the 
proposed  extent  of  the  operation  and  the  importance  of  the  contiguous 
structures.  In  every  instance,  however,  they  should  be  made  with  a  view 
to  securing  good  drainage,  provided  they  will  render  the  parts  accessible, 
and  not  expose  adjacent  important  structures  to  unwarranted  interference. 
Future  usefulness  being  one  of  the  most  important  factors,  the  insertions  of 
the  muscles  having  especially  defined  functions,  as  flexion  or  extension, 
must  if  possible  be  carefully  preserved.  If  it  be  necessary  to  divide  tendons 
they  should  be  incised  obliquely,  the  better  to  facilitate  subsequent  union 
(Fig.  348).  Should  it  be  needful  to  remove  the  bony  surfaces,  into  which 
tendons  or  ligaments  are  inserted,  the  periosteum  covering  these  surfaces 
should  first  be  carefully  peeled  off,  together  with  the  tendinous  attachments. 
All  diseased  and  loose  pieces  of  bone  should  be  removed,  together  with 
bony  irregularities  and  isolated  portions  of  articular  cartilage.  The  syno- 
vial membrane  should  be  preserved  entire  unless  it  be  diseased,  and  if  so 
the  diseased  portions  should  be  cut  or  scraped  away.  The  removal  of  the 
entire  shaft  of  a  bone  may  be  necessary  on  account  of  injury  or  disease, 
notably  the  latter.  In  such  cases  the  incision  should  be  a  free  one  and 
made  over  the  most  superficial  aspect  of  the  bone,  provided  that  important 
structures  do  not  intervene.  The  periosteum  is  then  elevated  proportion- 
ately to  the  extent  of  the  disease,  gradually  or  rapidly,  as  the  circumstances 
indicate,  and  the  diseased  bone  removed,  in  young  persons,  leaving  intacc, 
if  possible,  the  epiphyseal  extremities.  If  the  epiphyseal  cartilage  be  de- 
stroyed, the  growth  of  the  bone  in  its  long  axis  will  be  interrupted.  It  is 
important  to  observe  this  fact  in  operations  upon  the  bones  of  adolescents, 
since  to  destroy  this  cartilage  will  cause  a  subsequent  shortening  of  the 
limb.  The  consultation  of  any  standard  work  on  anatomy  will  enable  the 
surgeon  to  accurately  locate  the  epiphyseal  junctions,  and  will  likewise  in- 
form him  of  the  age  at  which  the  shafts  and  epiphyses  become  united. 

The  Time  for  Operation. — The  time  for  operation  must  be  governed  by 
the  condition  of  the  patient  and  of  the  part  to  be  operated  upon.  If  the 
patient  be  suffering  from  shock,  reaction  should  have  taken  place  prior  to 
operative  interference.  If  inflammation  of  the  bone  and  contiguous  tis- 
sues have  occurred,  good  drainage  should  be  established,  and  the  opera- 
tion deferred  until  the  acute  symptoms  subside.  If  the  operation  be 
for  necrosis,  the  diseased  bone  should  have  separated  before  the  attempt 
is  made. 

The  instruments  employed  in  excision  are  varied  in  number  and  shape, 
and  must  be  selected  according  to  the  peculiarities  of  the  case  (Fig.  375). 
The  scalpels  should  be  broad  and  strong.  The  retractors  must  likewise  be 
strong,  and  possess  a  hooklike  curve,  otherwise  they  will  slip  from  the 
wound.  The  periosteotomes,  elevators,  and  rugines  vary  in  shape,  but  should 
possess  a  blunt,  non-cutting  edge.  These  instruments  must  be  used  with 
care,  otherwise  the  function  of  the  periosteum  will  be  destroyed,  and  may 
even  be  followed  by  sloughing.  The  bone-cutting  instruments  are  bone- 
cutting  forceps  and  saws  of  various  sizes  and  shapes.     The  straight  bone 


OPERATIONS  ON  BONES. 


363 


•TiiTnnr  rrrinnvwpr 


Fig.  375..— Instruments  employed  in  excisions  of  the  extremities. 
a  Scalpels,     b.  Thumb  forceps,    c.  e.  Straight  and  curved  bone-cuttin-  forceps,     d.  Ron- 
Tem      f.  Snoncje  holder,     g.  Periosteotome.      h.  Farabceuf's  bone-holding  forceps. 
I    k'  Sti-ono-  straight  and  curved  scissors.      I,  m.  Engines.      /(Strong   retractor. 
p.  Spatula,     q.  Lifting  back,  keyhole,  and  Gigli-Haertel  saws.    Forcipressure,  liga- 
tures, etc.,  are  required. 


364 


OPERATIVE  SURGERY. 


forceps  is  the  most  available  for  general  purposes.    The  gnawing  forceps  or 
rongeur  is  of  inestimable  value  in  removing  bony  projections. 

The  Bone-holding  Forceps. — The  bone-holding  forceps  vary  somewhat 
in  their  grasping  and  holding  powers,  consequently  the  surgeon  is  governed 


Fm.  376.— Chain  saw. 

in  the  selection  of  this  instrument  by  its  suitability  for  the  purpose  at  hand 
(Figs.  375,  h,  and  378,  c) .  The  varieties  of  saws  are  numerous,  among  which 
are  the  chain  saw  and  the  straight  saw  with  or  without  an  adjustable  back 
(Fig.  375,  q).  The  chain  saw,  as  the  name  indicates,  is  composed  of  numer- 
ous links  or  sections,  having  a  handle  at  each  extremity  on  which  to  draw* 
while  sawing  (Fig.  376).  To  apply  the  saw,  remove  the  handle  from  the 
hook  and  carry  the  end  beneath  the  bone — the  cutting  edge  being  upward — 
by  means  of  a  thread  and  a  curved  needle ;  or  the  "  chain-saw  carrier  "  (Fig. 
377)  may  be  employed  instead.  Eeadjust  the  handle,  and  carry  the  saw 
around  the  bone  at  an  angle  of  about  forty-five  degrees 
and  draw  the  instrument  from  side  to  side.  The  saw 
should  not  be  jerked  or  be  allowed  to  kink,  but  should  be 
kept  taut  while  being  used  for  fear  of  clamping  or  break- 
ing. This  instrument  is  employed  in  dividing  bones  which 
are  nearly  surrounded  by  the  soft  parts.  The  Gigli-Haertel 
saw  bids  fair  to  displace  the  chain  saw,  in  minor  work,  as  it 
is  cheap,  easily  cleansed,  not  liable  to  clamp  or  bind ;  the 
latter  being  expensive,  often  of  uncertain  utility,  and  diffi- 
cult to  cleanse.  Fig.  437  represents  a  saw  of  great  prac- 
tical worth.  The  blade  is  adjustable,  and  its  cutting  sur- 
face can  be  turned  in  any  direction.  It  has  therefore  a  uni- 
versal application  which  renders  it  superior  to  the  chain 
saw  except  in  isolated  cases.  The  gouges,  chisels,  and  mal- 
let are  required  to  thoroughly  remove  all  diseased  bone. 
The  former  of  these  instruments  differ  in  size  and  shape  in 
order  that  the  intricacies  of  the  wound  may  be  reached. 

The  Surgical  Engine. — The  surgical  engine  is  the  out- 
come of  the  dental  engine,  the  former  being  the  stronger 
and  provided  with  suitably  constructed  knives,  burrs,  drills, 
and  saws.  These  addenda  are  connected  to  a  hand  piece 
which  is  attached  to  a  flexible  wire  cable  that  permits  the 
easy  holding  and  directing  of  their  rapidly  revolving  surfaces.  The  rapidity 
of  their  action — two  to  three  thousand  revolutions  per  minute — lessens  the 
pain  and  the  injury  done  to  important  parts.  The  engine  can  be  used  with 
advantage  in  bone  surgery.  It  is  expensive,  somewhat  cumbersome,  and 
therefore  better  fitted  for  hospital  than  for  general  practice.     The  various 


Fig.  377.— Chain- 
saw  carrier. 


OPERATIONS  ON  BONES.  365 

appliances  that  characterize  the  surgical  engine  can  he  attached  equally 
well  to  the  electrical  motor  that  propels  the  excellent  saw  devised  by  Powell 
(Fig.  281). 

The  treatment  of  excision  wounds  in  nearly  all  instances  is  at  the  outset 
substantially  the  same.  Eest  and  thorough  drainage,  together  with  strict 
antiseptic  measures,  constitute  the  basis  of  treatment.  Eest  can  he  secured 
by  the  use  of  various  forms  of  movable  or  immovable  splints.  The  special 
treatment  of  individual  instances  will  be  stated  in  connection  with  the  re- 
spective operations. 

EXClSIO?f   OF    THE   BONES    OF    TITM   FACE. 

The  great  vascularity  of  the  soft  parts  of  the  face  and  the  need  of  avoid- 
ing unnecessary  disfigurement  require  ample  preparation  for  the  control  of 
hfemorrhage  and  call  for  localization  of  the  incisions  in  the  course  of  ex- 
isting and  prospective  facial  lines.  An  abundance  of  ligatures  and  forci- 
pressure,  together  with  assistants  competent  to  catch  bleeding  points  and 
control  the  escape  of  blood  by  digital  pressure,  should  be  at  command. 
In  some  instances  temporary  or  permanent  ligature  of  one  or  both  of  the 
external  carotid  arteries  to  control  bleeding  may  properly  be  considered 
(Fig.  378). 

Excision  of  the  Upper  Jaw. — Excision  of  the  upper  jaw  is  performed  for 
various  diseases  connected  either  with  the  bone  structure  itself  or  the  cavi- 
ties with  which  it  is  associated.  In  all  instances  the  periosteum  should  be 
preserved  except  in  those  in  which  the  bone  is  invaded  by  malignant  disease, 
and  the  mucous  membrane  of  the  part  be  well  scrubbed  before  operation. 

The  RemarJcs. — The  patient  is  anaesthetized  and  placed  upon  the  back, 
either  with  the  head  slightly  raised  or  markedly  depressed  (Eose).  In  the 
latter  (Fig.  796)  blood  does  not  escape  into  the  larynx,  but  into  the  upper 
and  posterior  part  of  the  pharynx.  This  position  impedes  respiration  some- 
what by  undue  stretching  of  the  tissues  of  the  anterior  cervical  region. 
However,  if  the  foot  of  the  table  be  raised,  the  need  for  depression  of  the 
head  will  be  obviated  in  a  degree.  If  the  head  be  elevated,  the  blood  can 
with  care  be  kept  from  the  larynx  either  by  constant  sponging,  or  tam- 
poning the  pharynx  around  a  large  catheter  or  rubber  tube,  or  permitting 
the  patient  to  be  sufficiently  conscious  to  dislodge  it.  Still  another  method 
is  to  confine  the  patient  in  a  rocking  chair,  tipped  forward  or  backward  as 
circumstances  require.  In  this  instance  morphin- chloroform  narcosis  in- 
duced by  a  hypodermic  injection  of  morphine  followed  by  the  inhalation 
of  chloroform  until  excitement  is  manifested  when  the  chloroform  is  de- 
creased, can  be  employed.  The  patient  suffers  but  little  pain,  is  conscious 
and  spits  out  or  swallows  the  blood,  as  directed.  However,  the  danger  of  cere- 
bral anaemia  while  in  the  upright  position  must  be  kept  in  view  and  its 
slightest  manifestation  heeded  and  the  patient  placed  on  the  back  with  the 
head  lowered  during  the  remainder  of  the  operation.  The  surest  of  all  is 
to  perform  a  preliminary  tracheotomy  and  then  tampon  the  floor  of  the 
pharynx.  Preliminary  tracheotomy  is  not,  as  a  rule,  necessary  unless  the 
operation  be  complicated  with  a  very  vascular  morbid  growth  requiring  re- 


366 


OPERATIVE   SURGERY. 


pSr-w 


Fig.  378. — Instruments  employed  in  excision  of  bones  of  the  face. 
Liston's  curved  bone-euttin£?  forceps,  b.  Rongeur,  c.  Fergusson's  lion-jaw  forceps. 
d  Toofeh-pulling  forceps,  e.  Small  crown  trephine.  /.  Sponge  holder,  g.  Keyhole 
saw.  h.  Sequestrum  forceps,  i.  Volsellum  forceps,  h.  Mouth  gag.  I.  Trache- 
otomy tube.  TO.  Bone  drills,  n.  Rugine.  p.  Curved  and  straight  scissors,  q.  Peri- 
osteotome.  Scalpels,  mallet  and  chisels  (Pig.  374),  harelip  pins,  silkworm  gut,  and 
aseptic  cotton  yarn  for  the  pins,  are  required. 


OPERATIONS  ON  BONES.  36Y 

moval.  However,  there  seems  to  be  little  doubt  of  the  fact  that  the  post- 
operative dangers  are  lessened  sufficiently  by  preliminary  tracheotomy  to 
warrant  its  frequent  employment.  Whether  the  operation  of  tracheotomy 
shall  be  merged  with  the  profounder  one  or  be  practiced  a  few  days  in  ad- 
vance of  the  latter,  can  not  be  wisely  determined  except  by  careful  consid- 
eration of  the  demands  in  this  respect  of  individual  cases.  If  the  important 
associated  anatomy  be  carefully  regarded  before  beginning  the  operation, 
much  time  and  not  a  little  loss  of  blood  will  be  saved. 

Partial  and  complete  excision  of  the  upper  jaw  are  practiced.  In  the 
former  the  seat  of  the  operation,  the  means  of  accomplishment,  and  the 
method  of  practice  will  be  suggested  by  the  principles  of  action  that  char- 
acterize the  more  extensive  operative  procedures  of  excision. 

Complete  Excision — Anatomical  Considerations. — The  bony  connections 
to  be  divided  are  (Fig.  379)  :  1.  Through  the  nasal  process  of  the  superior 
maxilla  and  the  lachrymal  and  ethmoid  bones  (1,  1')  ; 
across  the  floor  of  the  orbit,  then  either  through  the 
malar  process  of  the  superior  maxilla  (2)  ;  or,  if  the 
malar  bone  also  is  to  be  removed,  through  the  frontal 
process  of  the  malar  and  the  zygoma (3',  3').  Finally, 
division  of  the  palate  process  of  the  superior  maxilla 
and  horizontal  plate  of  the  palate  bone  (3,  4')  is  re- 
quired. The  internal  maxillary  artery  in  the  spheno- 
maxillary fossa  and  the  branches  of  the  facial  artery 
running  through  the  external  soft  parts  are  the  only 
vessels  that  will  cause  troublesome  haemorrhage.  Sten- 
son's  duct  must  be  avoided,  as  it  passes  from  the    Fig,   379.— Division    of 

parotid  gland  on  a  line  extending  from  the  lobule        the  bony  connections 
»,,  ,  .^  1,  /iiT  «,i  of  the  superior  max- 

ot   the  ear  to  midway    between   the   border   oi   the        jUa. 

lip  and  the  ala  of  the  nose  to  empty  into  the  mouth 

opposite  the  second  molar  tooth.  The  superior  branches  of  the  facial  nerve 
may  be  divided  unnecessarily  if  the  course  of  the  incision  be  irregular  or  the 
extent  or  depth  be  too  great.  All  anticipated  complications  should  be  care- 
fully studied  and  provision  made  for  their  prevention  and  treatment.  Loss 
of  blood,  however,  is  the  only  one,  in  addition  to  the  shock  common  to  all 
operations,  that  demands  close  attention  at  the  outset.  Haemorrhage  from 
the  facial  and  internal  maxillary  arteries,  while  often  profuse,  can  be 
promptly  controlled  by  pressure. 

The  Lines  of  Incision. — The  lines  of  incision  may  be  made  within  or 
from  without  the  buccal  cavity  (Fig.  380).  The  removal  of  the  bone  from 
within  the  buccal  cavity  is  tedious,  as  the  space  is  limited  and  the  opportunity 
to  control  haemorrhage  comparatively  inadequate.  At  the  present  time  ex- 
ternal incisions  only  are  employed  in  all  except  special  cases.  These  incisions 
can  be  classed  as  the  outer  and  the  median.  The  former  (Lizar's)  is  begun 
at  the  angle  of  the  mouth  and  carried  in  a  cun^ed  course  upward  and  out- 
ward to  the  malar  process  (Fig.  380,  a)  ;  if  more  room  be  needed  the  first 
incision  may  be  extended  (a),  and  also  a  second  may  be  made  through  the 
upper  lip  to  the  nostril.     This  method  exposes   Stenson's  duct  and  the 


368 


OPERATIVE  SURGERY. 


branches  of  tlie  seventh  nerve  to  injury,  and  is  followed  by  a  conspicu- 
ous scar. 

Liston  made  an  incision  from  just  below  the  external  angular  process  of 
the  frontal  bone  to  the  angle  of  the  mouth  (Fig,  380,  c) ;  if  necessary,  a  sec- 
ond (c')  along  the  zygoma  joining  the  first,  and  even  a  third  from  the  nasal 
spine  of  the  maxilla  downward  through  the  lip  in  the  median  line  (Fig. 
382).  Velpeau,  like  Lizar,  made  a  single  curved  incision  with  the  convexity 
downward  from  the  angle  of  the  mouth  to  the  center  of  the  malar  bone,  and 
even  to  the  angle  of  the  orbit  (Fig.  3  80,  a,  a'),  if  necessary.  Langenhech  made  a 
U-shaped  incision  through  the  cheek,  with  the  convexity  extending  downward 
to  near  the  line  of  junction  of  the  upper  lip  with  the  cheek,  reaching  from  the 
point  of  attachment  of  the  nasal  bone  with  its  cartilage  to  the  middle  of  the 
malar  bone  (Fig.  384,  a).  In  this  operation  Stenson's  duct  may  be  cut  and 
many  branches  of  the  facial  nerve  are  divided,  besides  which  a  conspicuous 
scar  remains.  Another  and  an  admirable  incision,  Fergussons,  begins  from  a 
point  half  an  inch  below  the  inner  angle  of  the  eye,  and  following  the  furrow 
between  the  cheek  and  the  nose  terminates  by  passing  through  the  middle  of 
the  upper  lip  (Fig.  380,  &).  To  this  may  be  added  an  incision  (&'),  at  a  right 
angle  with  the  vertical  one,  an  inch  or  so  in  length,  extending  outward  half 
an  inch  below  the  orbit  (Weber) ;  it  may  be  extended  to  the  external  angle 
of  the  orbit  and  the  zygoma  if  necessary.  In  this  incision  the  coronary  and 
angular  arteries  only  are  divided.  Fergusson  sometimes  supplemented  the 
vertical  median  incision  with  an  outer  one  similar  to  Lizar's  (Fig.  380,  a). 
Gensoul,  beginning  just  below  the  inner  canthus,  made  a  nearly  vertical 

incision  down  to  the  bone,  through 
the  lip  opposite  the  bicuspid  tooth 
(Fig.  382,  V) ;  a  second  incision  of 
similar  depth  and  joining  the  first 
at  a  right  angle  on  a  level  with  the 
floor  of  the  nose  was  made  outward 
to  the  malar  bone ;  a  third  was  car- 
ried upward  from  this  point  to  the 
external  angular  process,  thus  com- 
pleting a  flap  of  commodious  di- 
mensions, but  one  followed  by  con- 
siderable disfigurement  and  rarely 
employed. 

The  Operation  hy  the  Median 
Incision;  Removal  of  the  Whole  Bone 
(Fergusson). — The  middle  incisor 
tooth  corresponding  to  the  side  to 
be  operated  upon  is  drawn,  the  facial 
artery  compressed  on  both  sides  by 
an  assistant,  and  the  posterior  nares  are  plugged.  The  primary  incision  is 
begun  half  an  inch  below  the  inner  angle  of  the  eye,  and  carried  along  the 
side  of  the  nose  around  the  naso-labial  junction  to  the  median  line  of  the  lip, 
thence  downward  through  its  free  border  (Fig.  380,  &).    Firm  sponge  pres- 


FiG.  380. — Lines  of  incision  in  removal  of 
upper  jaw.  a,  a'.  Lizar  and  Velpeau. 
b,  h'.  Fergusson- Weber,    c,  c'.  Liston. 


OPERATIONS  ON  BONES. 


369 


Fig.  381. — Division  of  processes  of  superior  maxilla. 


sure  promptly  follows  the  course  of  the  knife.  The  haemorrhage,  after  the 
division  of  the  lip,  is  controlled  at  either  side  of  the  incision  with  the  thumbs 
and  fingers  of  an  assistant  or  Ijy  strong  Langenbeck  serre-fines  (Fig.  103,  h). 
The  latter  are  tireless,  thoroughly  effective,  and  no  hindrance  to  the  operator. 
The  secondary  incisions  along  the  border  of  the  orbit  (&'),  etc.,  are  made  only 
when  necessary.  The  knife  is  carried  rapidly  down  to  the  bone,  and  the  flap 
dissected  outward,  as  far  as  the  malar  bone  above  and  the  tuberosity  of  the 
maxilla  below.  During  the 
dissection  the  bleeding  points 
are  controlled  by  the  fingers 
of  the  assistant  or  by  forci- 
pressure.  The  vessels  should 
be  ligatured  with  catgut  be- 
fore the  bone  is  removed. 
The  cartilage  of  the  nose  is 
separated  from  the  bone  and 
turned  inward;  the  edge  of 
the  orbit  is  gained,  and  the 
periosteum  on  its  floor  sepa- 
rated and  pushed  backward 
and  upward  to  the  border  of 
the  spheno-maxillary  fissure 
by  means  of  an  elevator  or 
the  handle  of  the  scalpel. 
The  malar  process  is  now  divided  by  a  saw  or  with  bone  forceps  from  the 
outer  extremity  of  the  spheno-maxillary  fissure  (Fig.  381).  The  thin  floor 
of  the  orbit  is  divided  with  a  scalpel  from  the  inner  extremity  of  the 
spheno-maxillary  fissure  obliquely  forward  and  inward  to  the  nasal  pro- 
cess, and  the  nasal  process  severed  with  forceps  or  strong  scissors.  The 
soft  palate  is  separated  from  the  hard  transversely  inward  to  the  center, 
on  a  line  with  the  last  molar  tooth;  an  incision  is  made  through  the 
mucous  membrane  from  the  center  forward  in  the  median  line  to  the 
incisor  teeth,  also  through  the  nasal  mucous  membrane  at  the  side  of  the 
septum  from  behind  forward.  The  hard  palate  is  divided  at  the  side  of 
the  septum  corresponding  to  the  bone  to  be  removed  by  a  saw  or  bone  forceps 
(Fig.  381),  and  the  bone  is  seized  and  pressed  downward  to  break  up  its 
posterior  connections,  after  which  it  is  raised  and  twisted  slightly  from  side 
to  side  and  pulled  out,  bringing  with  it  some  portions  of  the  palate  bone  and 
pterygoid  process  of  the  sphenoid,  together  with  the  muscular  fibres  connected 
with  them.  If  the  mucous  membrane  of  the  hard  palate  be  not  diseased,  it 
can  be  saved  by  making  an  incision  through  it  along  the  alveolar  border  and 
pushing  it  inward,  together  with  the  periosteum,  to  the  median  line.  After 
the  removal  of  the  bone  the  periosteum  and  membrane  can  be  stitched  to  the 
side  of  the  cheek,  thus  excluding  the  mouth  from  the  cavity  above. 

The  Operation  hy  the  Median  Incision;  Removal  helow  the  Floor  of  the 
Orbit. — After  the  exposure  of  the  external  surface  of  the  superior  maxilla, 
as  in  the  preceding  method,  perforate  the  anterior  wall  of  the  antrum  with 


370 


OPERATIVE  SURGERY. 


a  drill  or  trephine ;  then,  with  the  bone  forceps  or  saw  inserted  into  the  open- 
insf,  divide  the  bone  inward  to  the  nasal  fossa,  and  outward  throiio-h  the  malar 
bone.  Aside  from  this  the  steps  are  similar  to  those  of  the  preceding  operation. 

Tlie,  Operation  ly  the  Subperiosteal  Method. — The  subperiosteal  method 
can  be  accomplished  through  either  of  the  median  incisions,  although  an 
external  one  is  preferred  by  some  surgeons  (Fig.  382).  The  external  inci- 
sion (Oilier)  is  made  from  the  middle  of  the  malar  bone  to  a  point  at  the 
upper  lip  one  third  of  an  inch  from  the  angle  of  the  mouth  (Fig.  382,  a).  It 
is  sometimes  necessary  to  make  a  second  incision  from  the  middle  of  the  lip 
upward  to  the  nose.  The  mucous  membrane  on  the  external  surface  of 
the  alveolar  process  is  divided  down  to  the  bone  by  an  incision  begin- 
ning at  the  line  of  junction  of  the  lateral  incisor  and  canine  teeth,  and 
carried  backward  to  and  around  the  posterior  molar  to  the  inner  surface 
of  the  alveolar  process,  thence  forward  along  this  surface  parallel  with 
the  external  incision  to  a  point  opposite  the  commencement  of  the  former 
incision,  then  obliquely  backward  and  inward  to  the  median  line  on  a  line 
corresponding  to  the  intermaxillary  suture  of  that  side.  The  anterior  ex- 
tremities of  the  external  and  internal  incisions  are  now  connected  by  a 
transverse  incision  carried  between  the  lateral  incisor  and  canine  teeth.  The 
periosteum  is  then  peeled  off  from  the  external  and  orbital  surfaces  of  the 
bone,  and  also  from  the  inner  surfaces  of  the  alveolar  process  and  the  hard 
palate  of  that  side ;  the  soft  palate  is  carefully  separated  from  the  hard. 
The  nasal  and  malar  processes  are 
divided  as  before,  the  canine  tooth  is 
drawn,  and  the  intermaxillary  bone 
separated,  together  with  the  hard 
palate  of  the  maxilla,  from  the 
contiguous  bone  borders,  by  the 
chisel,  saw,  or  forceps.  The  max- 
illa is  then  twisted  out,  and  the 
periosteal  borders  of  the  outer  and 
inner  surfaces  of  the  alveolar  pro- 
cess are  united.  Langenbeck's 
incision  admits  of  subperiosteal 
removal,  but  its  limited  extent 
hinders  considerably  the  necessary 
manipulative  measures,  and  corre- 
spondingly exposes  the  tissues  to 
undue  violence.  The  incisions — 
of  Lizar,  Yelpeau,  Langenbeck, 
Listen,  etc.— are  better  adapted  to  removal  of  a  limited  portion  of  the 
maxilla  than  of  the  entire  bone,  because  of  the  comparatively  small  amount 
of  bone  surface  exposed  by  them ;  and,  too,  they  are  objectionable  because 
of  greater  disfigurement  and  the  danger  of  injury  of  the  branches  of  the 
facial  nerve  and  of  Stenson's  duct. 

Although  it  is  more  dangerous  and  perplexing  to  remove  the  entire  max- 
illa through  intra-buccal  incisions,  still  any  part  of  it  or  the  entire  lower 


Fig.  382. — Lines  of  incision  in  removal 
upper  jaw.     a.  Oilier,     b.  Gensoul. 


OPERATIOXS  ON  BOXES.  371 

half  can  be  thus  removed  with  but  little  additional  trouble  to  the  surgeon 
and  danger  to  the  patient.  When  cosmetic  reasons  dominate  the  policy  of 
action,  the  latter  method  should  be  adopted,  even  though  the  entire  jaw  re- 
quire removal. 

The  Removal  below  the  Infra-orlital  Foramen — Intra-liiccal  Method. — 
Extract  the  teeth  in  the  line  of  proposed  bone  section  ;  pass  a  short  retrac- 
tion suture  through  the  upper  lip ;  draw  the  cheek  of  the  affected  side 
backward  with  a  buccal  retractor,  the  fingers  of  an  assistant,  or  an  extempo- 
rized retractor  ;  separate  the  mucous  membrane  of  the  cheek  from  the  gum 
from  the  site  of  proposed  section  of  the  jaw  back  to  the  posterior  molar 
tooth ;  push  the  soft  parts  upward  in  the  line  of  the  incision  to  the  site  of 
proposed  section  of  the  bone,  being  careful  to  avoid  injury  of  the  internal 
maxillary  artery  behind  and  the  infra-orbital  in  front ;  break  into  the  an- 
trum in  front  with  a  small  chisel,  and  with  a  chisel  and  mallet  cut  the  outer 
wall  in  either  direction  to  the  extent  of  proposed  removal ;  sever  the  mu- 
cous membrane  of  the  inferior  meatus  from  behind  forward  at  the  objective 
side  with  a  long-bladed  knife  ;  divide  the  soft  parts  at  the  roof  of  the  mouth 
in  the  line  of  proposed  bone  section  through  the  hard  palate  with  a  scalpel ; 
separate  the  soft  from  the  hard  palate,  and  then  with  a  long-bladed  bone 
forceps  or  a  bone  chisel  divide  the  alveolar  process  and  hard  palate,  cutting 
toward  the  center  with  a  quick,  sharp  action  ;  grasp  the  fragment  with  bone 
forceps  and  remove  it  in  the  manner  previously  described.  Check  haemor- 
rhage by  prompt,  firm  pressure,  and  pack  the  wound  as  in  other  methods. 

The  Comments. — It  is  very  important  indeed  to  preserve  the  canine 
tooth  in  this  operation,  if  possible,  because  the  disfigurement  is  then  not 
noticed  from  the  front ;  the  tooth  also  affords  attachment  and  support  to  the 
compensatory  appliance  made  by  mechanical  dentists  for  the  correction  of 
speech  and  disfigurement.  "When  the  bone-cutting  forceps  is  carried  cross- 
wise of  the  hard  palate,  the  bone  is  liable  to  fracture  at  either  side  of  the 
line  of  section ;  when  applied  antero-posteriorly,  however,  the  division  is 
easily  made  without  fracture.  The  horizontal  portion  of  the  hard  palate 
may  escape  notice  and  remain  behind  unless  this  contingency  be  anticipated 
and  the  parts  examined  with  the  finger  after  removal  of  the  maxilla. 

The  Partial  revioval  of  the  hone  is  practiced  for  relief  from  limited  disease 
of  the  jaw.  The  alveolar  process  can  be  readily  removed  with  gnawing  for- 
ceps, or  chisel  and  mallet,  through  the  mouth  ;  the  hard  palate  by  a  saw  or 
the  chisel  and  mallet. 

The  Removal  heloic  the  Infra-oriital  Foramen — Extra-buccal  Method. — 
Make  a  curved  incision  with  the  convexity  outward  from  the  ala  of  the  nose 
to  the  angle  of  the  mouth,  lying  if  possible  in  the  facial  crease ;  dissect  up 
the  soft  parts  and  open  the  nostril ;  expose  the  malar  process  of  the  superior 
maxilla ;  introduce  a  narrow  saw  into  the  nose  and  saw  outward  horizontally 
in  a  line  just  below  the  infra-orbital  foramen  to  the  outer  surface  of  the  bone 
and  through  the  malar  process  ;  detach  the  soft  from  the  hard  palate  ;  divide 
the  hard  palate  antero-posteriorly  and  remove  the  bones  with  the  lion  jaw 
forceps  as  before.  If  the  orbital  plate  alone  is  to  be  preserved,  employ  when 
practicable  the  vertical  portion  of  Ferguson's  incision,  the  line  of  section  of 


372 


OPERATIVE  SURGERY. 


the  bone  being  located  just  below  the  orbital  plate.  In  other  respects  the 
procedure  is  substantially  similar  to  removal  of  the  entire  jaw.  The  middle 
and  upper  portions  of  the  jaw  when  diseased  can  be  removed  independently 
through  a  like  incision  of  the  soft  and  hard  parts^,  supplemented  with  a  hori- 
zontal section  of  the  bone  from  the  nose  outward,  just  above  the  alveolar 
process,  thence  upward,  when  practicable,  to  the  sawed  malar  surface. 

The  superior  maxillce  may  he  removed  simultaneously  by  either  one  of  two 
methods  (Fig.  383)  :  1.  Make  an  incision  from  the  angle  of  the  mouth  to  the 
middle  of  the  malar  bone  on  each  side  (Fig.  383,  a,  a),  and  dissect  upward  the 
intervening  flaps ;  or,  2,  make  a  vertical  incision  (b)  along  the  ridge  of  the  nose, 
beginning  above  at  a  point  a  quarter  of  an  inch  below  the  level  of  the  lower 
borders  of  the  orbit,  and  continuing  through  the  lip  (Dieffenbach).  To  this 
may  be  added  a  transverse  incision  passing  through  the  upper  end  of  the 
vertical  one  and  extending  on  either  side  to  a  point  a  quarter  of  an  inch  below 
the  middle  of  the  orbit  {e,  e) ;  the 
outer  bony  attachments  are  divided, 
as  in  the  single  operation ;  the 
nasal  processes  are  divided  either 
by  forceps  or  the  saw,  and  both 
bones  are  removed  at  once,  not 
separately.  In  all  operations  for 
the  complete  removal,  the  superior 
maxillary  nerve  should  be  divided 
as  far  back  as  possible.  The  bones 
may  be  removed  consecutively  in 
the  same  manner  as  for  the  removal 
of  a  single  superior  maxilla. 

After  operation  the  wounds  are 
washed  in  each  instance  with  anti- 
septic fluid,  all  bleeding  points 
checked  either  by  ligature,  pres- 
sure, or  cautery,  and  the  cavity  is 
packed  with  antiseptic  gauze.  The 
external  incisions  are  closed   with 

sutures  and  readily  unite  in  three  or  four  days.  These  cases  make  a  satis- 
factory recovery  from  the  operation,  although  some  deformity  will  remain. 

The  stitches  are  removed  from  the  soft  parts  on  the  third  or  fourth  day; 
union,  as  a  rule,  then  being  complete. 

T%e  After-treatment. — The  degree  of  success  of  these  operations  will  de- 
pend on  the  cleanliness  of  the  part  and  the  nourishment  and  vigor  of  the 
patient.  The  wound  is  packed  lightly  with  gauze,  frequently  cleaned  with 
antiseptic  fluid,  and  the  patient's  head  so  placed  as  to  prevent  discharges 
collecting  in  the  wound  or  entering  the  mouth  and  throat. 

The  patient  should  be  nourished  freely  with  milk,  eggs,  etc.,  from  the 
outset.  If  the  taking  of  food  by  the  mouth  be  inexpedient,  rectal  alimenta- 
tion and  the  employment  of  the  stomach  tube  are  enjoined.  If  food  be 
taken  in  the  usual  manner,  rinsing  of  the  mouth  and  repacking  of  the 


Fig.  383. — Lines  of  incision  in  simultaneous 
removal  of  the  superior  maxilla,  a,  a. 
Lateral  incision,  h,  e.  Median  transverse 
incision. 


OPERATIONS  ON  BONES.  373 

wound  should  follow  promptly  to  prevent  decomposition.  The  strength  of 
the  patient  ouglit  not  to  be  depleted  by  long  or  close  confinement  in  bed. 
A  prompt  getting  up  is  an  important  factor  of  success.  Fresh  air  is  needed, 
not  only  for  the  usual  reasons,  but  also  for  the  sj)ecial  purpose  of  purification 
of  the  upper  respiratory  passages. 

The  Results. — The  results  of  these  operations  are  good  so  far  as  immedi- 
ate loss  of  life  is  concerned,  as  death  rarely  happens  from  the  operation 
alone.  If  the  removal  be  done  for  malignant  growths  the  prognosis  for  ulti- 
mate recovery  is  unfavorable.  In  substantially  complete  removal  primary 
hemorrhage  caused  death  in  four  per  cent;  erysipelas,  septicaemia,  and 
other  complications  in  about  twenty-five  per  cent  of  two  hundred  and  thirty 
cases,  as  analyzed  by  the  author.  The  influence  on  speech  arising  from  the 
defect  in  the  hard  palate  can  be  completely  remedied  by  the  application  of  a 
rubber  plate  to  the  entire  roof  of  the  mouth  by  an  expert  mechanical  den- 
tist. The  plate  should  be  placed  on  the  surface  and  not  in  the  opening,  for 
if  it  be  permitted  to  thus  encroach  on  the  latter  the  continuous  and  active 
tendency  of  the  opening  to  closure  by  growth  from  the  hard  borders  will  be 
arrested  by  the  appliance,  to  the  great  discomfort  of  the  patient.  If  un- 
hindered, the  opening  will  be  reduced  in  a  few  years  to  at  least  one  third  or 
one  fourth  the  original  size  by  Nature's  efforts  alone.  In  order  that  the 
artificial  appliance  may  be  held  in  proper  place  the  canine  tooth  and  the 
intermaxillary  bone  of  the  affected  side  should  be  preserved  if  possible. 
If  the  operation  is  done  for  the  removal  of  malignant  disease  of  the  jaw 
no  chafing  of  the  roof  of  the  mouth  or  side  of  the  cheek  by  the  plate 
should  be  allowed.  Therefore,  in  these  cases  artificial  teeth  should  be 
omitted,  in  order  to  avoid  the  pressure  and  friction  of  the  plate  incident 
to  their  use. 

About  thirty  per  cent  die  when  both  bones  are  removed  simultaneously. 

Excision  of  the  Lower  Jaw. — Excision  of  the  lower  jaw  requires  no  ad- 
ditional instruments  ;  however,  the  precautions  referable  to  the  patient  are 
of  almost  equal  importance  with  those  relating  to  excision  of  the  upper  jaw, 
and  the  contiguous  anatomy  is  here  even  more  important. 

The  Anato7nical  Considerations. — The  facial  artery  runs  beneath  and 
across  the  lower  border  of  the  bone  on  the  outer  surface,  and  at  the  anterior 
border  of  the  masseter  muscle;  the  parotid  gland  lies  behind  the  ramus,  and 
often  overrides  it.  The  external  carotid  artery,  as  it  passes  through  the 
gland,  is  closely  associated  with  the  posterior  border  of  the  bone.  The  in- 
ternal maxillary  artery  runs  closely  behind  and  to  the  inner  side  of  the  neck 
of  the  condyle.  The  inferior  dental  artery  passes  along  the  inner  surface  of 
the  ramus  to  enter  the  inferior  dental  canal.  The  superior  division  of  the 
facial  nerve  crosses  the  outer  border  of  the  neck  of  the  condyle.  Stenson's 
duct  extends  across  the  masseter  muscle  on  a  line  parallel  with  and  about  an 
inch  below  the  lower  border  of  the  z3^goma,  opening  into  the  mouth  oppo- 
site the  second  molar  tooth  of  the  upper  jaw.  The  lingual  nerve  lies  near 
the  inner  surface  of  the  ramus,  close  to  the  bone,  just  below  the  last  molar 
tooth. 

The  genio-hyo-glossus  muscles  are  attached  to  the  superior  genial  tuber- 
56 


374  OPERATIVE  SURGERY. 

cles,  and,  if  incautiously  detached,  will  permit  the  tongue  to  fall  back- 
ward and,  close  the  glottis.  It  is  important,  when  possible,  to  preserve  the 
attachments  of  the  muscles  of  mastication  on  account  of  their  action  on  the 
lower  jaw. 

Partial  and  complete  removal  is  practiced;  a  partial  removal  may  include 
any  fractional  portion  of  the  bone. 

The  Remarks. — The  incisions  for  removal  of  the  lower  jaw  may  be  made 
within  the  mouth  or  on  the  external  surface.  If  the  whole  or  a  lateral 
half  is  to  be  removed,  an  external  incision  must  be  made.  The  portion  in 
front  of  the  molar  teeth,  and  even  that  in  front  of  the  ramus,  can  be  ex- 
cised through  an  internal  incision  alone ;  the  latter  method  is,  however,  often 
attended  by  vexatious  diflQculties,  and  is  hardly  warrantable  except  in  selected 
cases.  The  ramus  and  portions  of  the  body  of  the  bone  behind  the  teeth 
can  be  removed  through  an  external  incision  without  opening  into  the  buccal 
cavity,  provided  the  periosteum  be  carefully  raised.  In  the  same  manner 
the  body,  or  any  portion  of  it,  may  be  taken  away  if  the  corresponding  teeth 
be  absent.  If  the  teeth  be  present  the  periosteum  should  be  carefully  de- 
tached and  the  bone  with  the  teeth  removed,  after  which  the  opening  in  the 
buccal  membrane,  caused  by  the  withdrawal  of  the  teeth,  can  be  closed  by 
sutures.  If  the  jaw  be  the  seat  of  phosphoric  or  other  necrosis,  it  may  be 
gradually  enucleated  from  its  surrounding  involucrum  through  an  external 
opening  by  the  indirect  method  (page  361),  and  the  teeth  may  even  remain 
in  the  new  growth  of  bone.  Unfortunately,  however,  when  processes  of  a 
malignant  nature  call  for  the  operation,  these  conservative  methods  are  of 
no  avail,  since  the  operation  must  be  directed  to  the  removal  of  all  the  dis- 
eased tissues.  When  possible  the  incision  in  the  buccal  lining  should  be 
closed  and  the  wound  drained  externally.  This  course  will  keep  the  mouth 
clean  and  prevent  swallowing  the  discharges. 

The  Operation  of  Excision  of  the  Central  Portion  of  the  Loiver  Jaw. — 
Pass  a  stout  ligature  through  the  tongue  well  behind  its  tip  to  prevent  tear- 
ing out,  and  tie  the  ends  to  form  a  loop  which  will  be  convenient  for  keep- 
ing the  tongue  from  falling  backward.  The  assistant  stands  behind  the 
head  of  the  patient,  holds  the  loop  firmly,  and  at  the  same  time  compresses 
the  facial  arteries  where  they  pass  across  the  jaw,  or  seizes  the  lower  lip  at 
the  angles,  between  the  thumbs  and  fingers,  rendering  it  tense,  and  at  the 
same  time  arresting  the  circulation.  The  operator,  standing  in  front,  makes 
a  vertical  incision  through  the  median  line  down  to  the  bone,  to  the  lower 
border  of  the  symphysis  menti,  raises  the  periosteum,  if  practicable,  to  the 
extent  of  the  proposed  section,  draws  a  tooth  at  each  point  where  the  bone 
is  to  be  divided,  saws  the  bone  at  these  points,  and,  drawing  the  fragment 
forward,  separates  the  attachments  of  the  muscles  as  closely  as  possible  to 
their  insertion  and  removes  the  part.  The  flaps  are  united  with  silver  wire 
or  silkworm  gut  extending  through  the  mucous  membrane.  The  vermilion 
border  of  the  lip  is  carefully  adjusted  and  united  with  hare-lip  pins  or  silk- 
worm-gut sutures.  If  the  tongue  falls  backward  its  severed  muscular  attach- 
ments can  be  drawn  forward  and  connected  with  the  incision  in  the  median 
line  by  a  deep  suture  passed  through  the  lip.     The  anterior  portion  of  the 


OPERATIONS  ON  BONES. 


375 


bone  can  be  easily  reached  through  a  curved  incision  made  along  its  lower 
border,  or  by  an  internal  one  corresponding  to  the  fold  of  the  buccal  mu- 
cous membrane.  The  lip  is  depressed  over  the  symphysis  mcnti,  and  the 
bone  is  divided  and  removed  as  before.  In  .complete  removal  of  a  portion  of 
the  body  of  the  bone,  the  bone  need  not  be  sawed  through  entirely  at  either 
place,  but  nearly  so  at  both,  and  finally  fractured  at  these  points  with  bone- 
cutting  forceps.  The  excision  of  the  central  or  any  part  of  the  JDone  requires 
that  the  divided  ends  be  subsequently  kept  properly  separated,  or  their  ap- 
proximation will  destroy  the  contact  of  the  biting  surface  with  that  of  the 
upper  jaw  during  mastication.  A  perfect  approximation  of  the  biting  sur- 
faces is,  however,  almost  impossible,  and  the  operation  should  not  be  at- 
tempted with  the  expectation  of  securing  complete  functional  restoration. 
If  the  condition  of  the  tissues  will  permit,  the  separating  agent  can  be 
properly  fixed  to  the  divided  ends  at  the  time  of  operation,  and  may  serve 
for  a  time  to  keep  the  fragments  apart.  The  interdental  splint  prepared 
before  operation  and  applied  to  the  remaining  teeth  afterward  offers  the 
best  solution  of  the  problem  known  to  the  writer.  Even  by  this  means  the 
tendency  to  internal  displacement  of  the  posterior  fragment  is  rarely  entirely 
controlled. 

The  Operation  of  Excision  of  a  Lateral  Portion  of  the  Lower  Jaw. — 
Make  an  external  incision  along  the  under  border  of  the  portion  to  be  re- 
moved down  to  the  bone  (Fig.  384).  If 
necessary,  the  incision  may  be  turned 
upward  anteriorly  at  a  right  angle  toward 
but  not  through  the  lip.  If  the  con- 
dition of  the  parts  will  permit,  the  peri- 
osteum is  reflected  off,  the  bone  divided 
in  front,  external  to  the  insertion  of  the 
genio-hyo-glossus  muscle,-  and  if  possible 
turned  outward,  and  the  tissues  separated 
back  to  the  point  of  posterior  section; 
the  bone  is  then  divided  at  this  latter 
situation  with  a  saw,  the  fragment  re- 
moved, and  the  wound  dressed  as  before. 

The  Operation  of  Excision  of  a  Lat- 
eral Half  of  the  Lower  Jaw. — Commence 
the  incision  about  an  inch  and  a  half 
below  the  zygoma,  and  carry  it  downward 
along  the  posterior  border  of  the  ramus 
and  beneath  the  body  of  the  jaw  to  the 
symphysis  menti,  carefully  exposing  the  facial  artery  and  tying  it.  If  the 
operation  be  for  necrosis  this  incision  will  be  sufficient ;  if  for  other  disease, 
the  lower  lip  is  cut  perpendicularly  through  its  center  to  meet  the  longi- 
tudinal incision  (Fig.  384,  h).  The  bone  is  exposed  in  front  by  peeling  off 
the  periosteum  and  sawed  through  just  to  the  outer  side  of  the  insertion 
of  the  genio-hyo-glossus  muscle  (Fig.  385,  G)  if  possible,  the  end  of  the  por- 
tion to  be  removed  is  pulled  outward,  and  the  remaining  attached  tissues 


Fig.  384. — Lines  of  incision  in  the  re- 
moval of  upper  and  lower  jaws. 
a.  Langenbeck.  &,  V.  Removal  of 
lower  jaw. 


376 


OPERATIVE  SURGERY. 


separated  either  by  cutting  or  by  a  periosteotome,  back  to  the  beginning  of 
the  incision.  Depress  the  fragment  forcibly ;,  and  if  possible  detach  the  tem- 
poral muscle  with  scissors  or 
the  periosteotome,  otherwise  di- 
vide the  coronoid  process  with 
a  fine  saw;  turn  the  bone  out- 
ward and  sever  the  insertions  of 
the  pterygoid  muscles,  being 
careful  to  avoid  cutting  the 
lingual  nerve;  draw  the  bone 
forward  forcibly  and  twist  it 
from  its  socket  (Fig.  386). 

If  the  primary  incision  be 
sufficient  to  expose  the  bone 
above  the  seat  of  the  disease, 
the  diseased  portion  is  removed 
and  the  upper  part  allowed  to 
remain.  If,  however,  it  be  im- 
portant to  accomplish  the  com- 
plete removal,  extend  the  in- 
cision upward  to  the  neck  of  the 
bone  (Fig.  384,  &'),  avoiding,  if 
possible,  Stenson's  duct  and  the 
cervico  -  facial  branch  of  the 
facial  nerve,  and  enucleate  the 
Fig.  385.— Lines  of  incisions  in  maxilte.  A,  B,  C.  condyle.  At  this  situation  the 
Excision  of  the  upper  jaw.  D.  Boeckels's  in-  condyle  must  be  hugged  close- 
cision.  E,  G.  Guerin's  incision.  F,  F.  Lan-  -,  n+hprwkp  +hp  intprnal  max- 
genbeck's  incision.  G.  Incision  in  removal  of  ^J'  OtUerwise  tue  internal  max 
lower  jaw.  E.  Incision  for  removal  of  portion  illary  artery  may  be  injured,  as 
of  alveolus.    I.  Esmarch's  incision  in  anchy-    -^  ^  immediately  behind  it. 

The  Operation  of  Excision 
of  the  Entire  Lower  Jaw. — Eemove  first  the  half  of  the  jaw  that  best  suits 
the  convenience  of  the  operator  in  the  manner  before  described.  A  ligature 
is  then  passed  through  the  tongue,  given  to  an  assistant,  and  the  remaining 
half  of  the  bone  excised  in  a  similar  manner.  Arrest  all  hemorrhage,  and 
close  the  wounds  with  sutures  in  such  a  way  as  to  accurately  coapt  the 
divided  buccal  borders. 

The  Operation  of  Excision  of  a  Portion  of  the  Alveolar  Process. — When 
the  extent  of  the  disease  will  permit,  the  alveolar  process  can  be  removed  down 
to  the  body  of  the  jaw  through  either  an  external  or  internal  incision,  the 
former  being  the  better,  by  rongeur,  chisel  and  mallet,  or  saw  (Fig.  385,  fi"). 
The  diseased  part  is  then  removed  and  the  wound  closed  as  before. 

The  Comments.— In  all  situations,  when  the  nature  of  the  disease  will 
permit,  the  periosteum  should  be  reflected  by  a  careful  yet  vigorous  use  of 
the  elevator.  The  insertions  of  ligaments  and  tendons  will  offer  the  only 
obstacle,  and  these  should  be  carefully  detached  by  a  sharp  knife  or  rugine 
so  that  a  continuity  of  the  periosteal  and  fibrous  tissues  will  remain. 


OPERATIONS  ON  BONES. 


377 


The  periosteum  in  young  subjects  may  reproduce  enough  bony  material 

to  give  a  fair  outline  to  the  face  and  serve  an  important  function  in  masti- 
cation. 

If  bone  be  not  reproduced,  the  periosteum  will  furnish  a  firm,  fibrous  base, 
which  may  be  utilized  for  artificial  appliances.  If  the  anterior  portion  of 
either  or  both  sides  be  removed,  the  gap  may  be  filled  in  by  an  artificial  den- 
tal appliance,  which  will  often  happily  maintain  the  symmetry  of  the  face 
and  become  useful  in  mastication. 

When  prudent  to  do  so,  as  much  as  possible  of  the  body  of  the  lower  jaw 
should  be  preserved,  since  it  will  form  an  excellent  foundation  for  a  compen- 
satory dental  appliance.  Whenever  the  disease  is  malignant  the  periosteum 
should  be  removed  with  the  bone  and  care  be  taken  that  none  of  the  dis- 
eased membrane  remains  in  the  wound.  It  is  also  necessary  in  such  cases 
to  remove  all  associated  structures  when  diseased,  such  as  glands,  floor  of  the 
mouth,  and  even  a  part  or  the  whole  of  the  tongue  itself. 

The  after  -  treatment  in 
operations  on  the  lower  jaw 
differs  in  no  essential  respect 
from  that  of  the  upper. 
Cleanliness  of  the  parts,  lib- 
eral alimentation,  and  the 
avoidance  of  swallowing  the 
discharges,  appeal  to  the  com- 
mon sense  of  all. 

The  Results. — Out  of  two 
hundred  and  forty-six  ex- 
cisions in  the  continuity  forty- 
six  died  ;  of  one  hundred  and 
fifty-three  disarticulations  of 
half  the  bone  thirty-six  died  ; 
in  twenty  operations  for  re- 
moval of  the  entire  jaw  one 
died.  It  will  be  seen  that 
death  has  followed  in  twenty  per  cent  of  all  the  cases.  Pyfemia,  erysipelas, 
and  exhaustion  were  the  principal  causes. 

Immobility  of  the  Inferior  Maxilla. — Immobility  of  this  bone  is  over- 
come wholly  or  in  part  by  the  establishment  of  a  false  joint  in  front  of  the 
seat  of  the  cause.  The  loss  of  function  is  usually  dependent  on  cicatricial 
contraction,  irreducible  dislocation,  or  anchylosis.  The  removal  of  a  wedge- 
shaped  piece  from  the  lower  border  of  the  jaw  or  from  the  alveolar  process 
has  been  practiced,  or  transverse  section  of  the  ramus  with  a  sharp  chisel  in- 
troduced through  the  mouth,  or  even  fracture  of  the  neck  when  the  con- 
dyle is  involved,  with  and  without  its  removal  of  the  latter,  has  relieved  the 
condition. 

The  Operatinn  hy  Removal  of  a  Wedge-shaped  Piece  (Esmarch). — Make 
an  incision  two  inches  in  length  down  to  the  bone,  along  the  lower  border  of 
the  jaw,  beginning  at  or  in  front  of  the  angle,  depending  upon  the  location 


Severine:  connections  of  inferior  maxilla. 


378  OPERATIVE  SURGERY. 

of  the  cause  of  the  immobility.  Avoid  or  tie  all  important  vessels  in  the 
course  of  the  incision,  expose  both  surfaces  of  the  bone  up  to  the  summit  of 
the  alveolar  process,  and  pull  a  tooth  at  that  situation  if  necessary.  Divide 
the  bone  with  a  saw  at  one  extremity  of  the  exposed  surface,  force  the 
other  extremity  through  the  wound,  and  remove  a  wedge-shaped  portion 
(Fig.  385, 1)  with  the  rongeur  or  saw,  the  base  of  which  should  not  exceed  a 
third  or  half  an  inch.  While  the  patient  is  still  under  the  influence  of  the 
anaesthetic  and  before  the  wound  is  closed,  ascertain  the  distance  that  the 
liberated  portion  can  be  separated  from  the  upper  jaw  with  moderate  force. 
Provide  suitable  drainage,  close  the  wound,  and  prevent  union  of  the  bones 
by  passive  motion. 

Bizzoli,  of  Bologna,  recommends  a  simple  section  of  the  bone  instead  of 
the  removal  of  a  wedge-shaped  piece.  However,  the  results  of  this  method 
do  not  warrant  its  substitution  for  the  former.  If  the  cause  of  the  immo- 
bility be  due  to  anchylosis  of  the  temporo-maxillary  articulation,  the  con- 
dyle should  be  removed,  or  the  ramus  be  so  divided  as  not  to  seriously 
impair  the  functions  of  the  masseter  muscle — that  is,  divided  beneath  that 
muscle. 

The  division  of  the  neck  of  the  bone  by  a  straight  chisel  introduced 
through  the  mouth  (Grube)  has  been  practiced.  After  either  operation  it 
may  be  necessary  to  divide  the  masseter  muscle  before  the  full  benefit  can 
be  experienced  from  the  division  or  the  removal  of  the  bone.  If  it  be  deter- 
mined to  remove  the  condyle,  an  incision  an  inch  and  a  quarter  in  length  is 
made  from  the  tragus  along  the  lower  border  of  the  zygoma,  the  soft  tis- 
sues, including  the  branches  of  the  facial  nerve,  are  drawn  downward  and 
the  joint  exposed,  then  by  means  of  a  chisel,  saw,  or  forceps  the  neck  of  the 
bone  is  divided  at  the  proper  place,  the  fragment  turned  outward  by  forceps, 
its  attachments  divided,  and  the  fragment  removed.  Passive  motion  should 
follow  the  same  as  before. 

The  Excision  of  the  Condyle. — Excision  of  the  condyle  of  one  or  both 
sides  is  practiced  for  cure  of  immobility  of  the  temporo-maxillary  articu- 
lation. 

The  Operation. — Make  a  vertical  incision  through  the  skin  and  fascia, 
about  three  fourths  of  an  inch  in  length  from  the  lower  border  of  the 
zygoma,  along  the  neck  of  the  bone  in  front  of  the  temporal  artery;  con- 
nect the  upper  end  of  the  incision  with  a  horizontal  one  of  similar  depth, 
an  inch  and  a  half  in  length,  passing  forward  along  the  lower  border  of  the 
zygoma,  and  turn  the  flap  thus  formed  downward  and  forward ;  expose  the 
neck  of  the  bone  and  capsule  of  the  joint,  and  during  the  time  carefully 
guard  from  injury  the  transverse  facial  artery,  the  duct  of  Stenson,  and 
the  facial  nerve  as  they  pass  forward  below  and  parallel  with  the  zygoma, 
in  the  order  above  stated;  retract  downward  and  backward  respectively 
the  borders  of  the  wound;  open  vertically  the  capsule  of  the  joint,  expose  the 
condyle,  and  saw  it  transversely  close  to  the  head  with  a  Gigli-Haertel  saw, 
saving,  if  practicable,  the  lower  fibers  of  the  external  pterygoid ;  turn  out 
the  condyle,  seize  it  with  forceps,  sever  the  remaining  connections,  remove 
the  fragment  preserving  the  capsule  and  the  intra-articular  fibro-cartilage; 


OPERATIONS  ON  BONES.  379 

open  the  jaw  and  estimate  the  effects  of  the  above  measures  on  its  mobility. 
If  ample,  then  introduce  the  sawed  end  into  the  joint,  close  the  capsule  with 
buried  sutures,  establish  drainage,  close  the  wound  of  the  soft  parts  with 
subcuticular  sutures  and  apply  the  dressing  with  the  jaw  closed. 

The  Remarhs. — The  operation  may  be  practiced  successfully  through 
the  horizontal  arm  of  the  incision  only,  thus  avoiding  the  dangers  incurred 
to  the  structures  below  in  making  the  vertical  one.  Thorough  asepsis  is 
essential  to  final  success.  The  detached  fibers  of  the  pterygoid  may  be 
stitched  to  the  periosteum  of  the  neck  of  the  bone.  Free  opening  of  the  jaw 
with  a  gag,  if  needed,  should  be  done  with  the  patient  still  under  anaesthesia. 
An  anaesthetic  may  be  needed  thereafter  in  passive  motion,  because  of  the 
pain  and  rigidity  incident  to  it.  In  severe  eases,  removal  of  the  coronoid 
process  may  be  practiced  to  secure  wider  range  of  motion.  Sometimes  tem- 
porary facial  paralysis  follows  a  too  free  or  careless  handling  of  the  soft 
parts  associated  with  the  facial  nerve. 

Excision  of  the  Sternum. — No  definite  plan  for  this  operation  can  be  out- 
lined. The  form  and  length  of  the  incisions  must  be  governed  by  the  loca- 
tion and  extent  of  the  disease.  The  diseased  bone  should  be  freely  exposed 
and  removed  in  the  usual  manner.  Care  must  be  observed  and  the  bone 
closely  followed,  else  the  pleural  cavity  will  be  opened.  When  possible,  sub- 
periosteal excision  should  be  done,  as  the  bone  is  quite  readily  reproduced. 
The  entire  sternum  is  reported  to  have  been  removed  by  Konig  on  account 
of  a  sarcomatous  tumor  involving  its  structure,  and  although  the  pericar- 
dium and  pleural  cavity  were  opened  the  patient  ultimately  recovered. 

The  Results. — Partial  excision  results  most  favorably;  only  one  in 
eighteen  has  died.    Under  asepsis  these  results  are  improved. 

Excision  of  the  Clavicle. — The  clavicle  is  excised,  entirely  or  in  part,  on 
account  of  various  morbid  conditions  and  extensive  injuries  of  the  bone. 
The  anatomical  relations  are  somewhat  intricate  and  perplexing,  especially 
when  the  normal  relations  are  changed  by  extensive  diseased  action  and 
.  traumatism.  The  muscular  and  ligamentous  attachments  of  this  bone  must 
be  carefully  studied,  for  it  is  with  a  knowledge  of  them  that  the  surgeon  is 
enabled  to  remove  the  bone  readily  and  safely  from  its  more  important  rela- 
tions. A  careful  scrutiny  of  the  "  contiguous  anatomy  "  on  the  following 
page  emphasizes  in  no  uncertain  way  the  need,  not  only  of  well-tested  ana- 
tomical knowledge  on  the  part  of  the  operator,  but  also  of  definite  ideas 
regarding  the  influence  of  various  forms  of  disease  on  the  structures  asso- 
ciated with  the  clavicle  as  well  as  on  the  bone  itself.  Morbid  processes  and 
injuries  involving  the  outer  end  of  the  clavicle  invest  operation  there  with 
but  little  difficulty  or  danger  as  compared  with  similar  conditions  when 
located  at  the  inner  extremity.  Many  structures  at  the  inner  and  middle 
parts  of  the  bones  are  of  such  vital  importance  as  to  beget  of  themselves 
special  dangers.  However,  it  should  not  be  assumed  that  all  growths  of 
the  clavicle  of  imposing  mien  are  necessarily  of  specially  dangerous  im- 
port, since  the  direction  of  the  growth  may  be  of  greater  operative  signifi- 
cance than  the  size.  In  any  event,  the  surgeon  should  be  prepared  for  the 
difficult  rather  than  for  the  easy  problems  of  a  case.    With  the  patient  in  the 


380  OPBRATIYE  SURGERY. 

proper  position  for  operation,  the  important  relations  are  ^^ell  expressed 
by  the  following  scheme: 

The  Contiguous  Anatomy. 

In  front. 
Attachments  of 
The  pectoralis  major  muscle. 
The  stern  o-mastoid  muscle. 
The  trapezius  and  deltoid  muscles. 
Above.  Below. 

The  external  jugular  vein.  The  cephalic  vein. 

The  branches  of  the  thyroid  axis.  ^ 

Clavicle. 
The  subclavian  artery. 

The  brachial  plexus. 

Behind. 

The  internal  mammary  artery i  i  v.  i# 

mi        1    1     •          •  r  sternai  naii. 

The  subclavian  vein ) 

The  external  jugular  vein. 

The  innominate  vein  at  the  right. 

The  thoracic  duct  at  the  left. 

The  pleura. 

The  Operation  of  Excision  of  the  Entire  Clavicle. — Anaesthetize  and 
place  the  patient  in  a  position  for  ligature  of  the  subclavian  artery.  If  the 
operation  is  for  necrosis,  make  an  incision  the  whole  length  of  the  bone 
parallel  with  its  long  axis.  If  necessary,  short  transverse  incisions  are 
added.  Expose  the  clavicle,  divide  the  periosteum,  and  with  the  elevator 
enucleate  the  diseased  bone  from  the  surrounding  tissues.  The  clavicle  can 
be  divided  through  the  center  and  each  half  removed  separately,  or  the  acro- 
mial end  can  be  detached  and  the  entire  bone  raised  from  without  inward. 
In  either  instance  the  articular  ends  and  their  connecting  ligaments  should 
be  preserved  if  possible. 

If  the  involucrum  be  weak  and  liable  to  bend  or  break  after  the  bone  is 
removed,  the  shoulder  must  be  held  outward,  backward,  and  upward  by 
means  of  the  method  employed  in  treatment  of  fracture  of  that  bone.  The 
indirect  method  of  sequestrotomy  (page  361)  can  be  performed  in  some 
instances. 

If  the  operation  is  for  the  removal  of  a  tumor  of  this  bone,  especially  of 
one  acutely  malignant  and  involving  any  considerable  portion  of  its  sur- 
rounding tissues,  it  is  certain  to  be  an  exceedingly  tedious  and  bloody  pro- 
cedure. 

The  smaller  the  size  of  the  tumor  and  the  less  its  vascularity  the  easier 
will  be  the  removal. 

The  Operation  for  Malignant  Growth  of  the  Clavicle. — Make  an  incision 
in  the  long  axis  of  the  bone  from  its  sternal  to  its  acromial  extremity.  If 
necessary,  this  is  crossed  by  a  vertical  incision  extending  from  the  posterior 
border  of  the  sterno-mastoid  muscle  to  the  upper  third  of  the  pectoralis 
major  muscle.  Make  these  incisions  as  deep  as  the  nature  of  the  growth 
will  permit,  and  dissect  the  flaps  from  the  tumor ;  separate  the  attachments 


OPERATIONS  ON  BONES. 


381 


of  the  deltoid  and  the  trapezius  muscles  on  a  director,  cutting  them  either 
with  a  knife  or  strong  curved  scissors,  being  careful  to  avoid  the  cephalic  vein 
which  lies  at  the  anterior  border  of  the  deltoid  muscle.  Divide  the  coraco- 
and  acromio-clavicular  ligaments,  raise  the  acromial  extremity  of  the  clavicle, 
and  thus  elevate  the  morbid  growth,  which  should  then  be  cautiously  sepa- 
rated from  the  surrounding  tissues.  The  nearer  the  approach  to  the  sternal 
extremity  of  the  clavicle  the  greater  will  be  the  necessity  for  caution,  since 
the  growth  may  be  connected  with  the  important  structures  located  in  this 
situation.  Finally,  divide  the  insertions  of  the  sterno-mastoid  and  the  pec- 
toralis  major  muscles  and  the  rhomboid  ligament,  and  carefully  disarticulate 
the  sternal  extremity  while  the  tumor  is  lifted  upward  and  inward  together 
with  the  clavicle. 

Either  extremity,  or  a  part,  of  the  clavicle  may  be  excised  by  making  a 
crucial  incision  down  to  the  bone,  at  a  site  corresponding  to  the  portion  to 
be  removed,  exposing  and  dividing  it  with  a  saw,  and  removing  the  frag- 
ment with  the  same  precautions  as  before  described. 

The  Precautions. — At  the  middle  third  the  large  vessels  lying  beneath 
the  bone  should  be  considerately  treated  to  prevent  hemorrhage  and  the 
admission  of  air  to  the  veins.  The  subclavius  muscle  at  this  situation  is  a 
valuable  guide,  as  it  lies  between  the  vessels  and  the  bone. 

The  results  of  the  operation  of  complete  excision  have  been  quite  favor- 
able. Of  seventy-three  cases  six  died  from  the  operation.  Exhaustion,  due 
to  loss  of  blood,  erysipelas,  etc.,  may  cause  death.  Nor'kur,  and  later  Mc- 
Burney,  have  each  had  a  case  with  perfect  function  of  the  arm  after  com- 
plete excision. 

Partial  excisions  give  a  death  rate  of  about  eight  per  cent  from  all 
causes. 

Excision  of  the  Scapula. — The  scapula  is  excised  on  account  of  gunshot 
injuries,  necrosis,  and  morbid  growths. 

The  whole  bone  may  be  removed,  or  the 
body,  angles,  or  spine  may  be  removed  sepa- 
rately. The  contiguous  anatomy  is  exten- 
sive, but  not  of  the  dangerous  character  of 
that  associated  with  the  clavicle.  To  its 
spine,  borders,  and  surfaces  numerous  and 
powerful  muscles  are  attached. 

At  the  upper  border  are  found  the 
suprascapular  vessels  and  nerves.  The  pos- 
terior scapular  artery  passes  down  its  ver- 
tebral border,  while  at  the  axillary  border 
the  subscapular  and  dorsalis  scapuh'e  ar- 
teries, the  axillary  artery  itself  and  the 
brachial  plexus  are  in  close  association  with  Fig.  387.— Excision  of  entire  scapula, 
the  bone. 

The  Operation  of  Excision  of  the  Entire  Scapula  (Fig.  38T). — Place  the 
patient  on  the  sound  side  close  to  the  edge  of  the  table.  Make  an  incision 
from  the  tip  of  the  acromion  process  along  the  spine  to  the  posterior  border 


382 


OPERATIVE   SURGERY. 


of  the  scapula,  a,  l.  Join  it  by  a  second  incision  extending  from  near  the 
middle  of  the  spine,  c,  to  the  inferior  angle  of  the  bone.  If  necessary,  a 
third  may  be  made  from  the  base  of  the  spine  to  the  posterior  superior  angle. 
Dissect  up  and  turn  aside  the  flaps  thus  indicated. 

Divide  the  attachments  of  the  deltoid  and  trapezius ;  disarticulate  the 
acromio-clavicular  articulation;   secure  the  subscapular  artery;  divide  the 

ligaments  and  tendons  around  the  glenoid 
cavity;  raise  the  coracoid  process  and 
carefully  sever  its  ligaments  and  muscular 
attachments;  raise  the  scapula  by  the 
inferior  angle  and  divide  its  remaining 
muscular  attachments  with  a  knife  or 
strong  scissors,  carefully  avoiding  the 
subscapular  and  posterior  scapular  ves- 
sels; remove  the  bone  and  tie  all  the 
bleeding  points ;  wash  with  an  aseptic 
solution ;  thoroughly  drain  and  close  the 
wound  and  dress  antiseptically.  Sir  W. 
Ferguson  and  Mr.  Pollock  thought  it 
better  to  raise  the  vertebral  border  of  the 
scapula  first  that  the  subscapular  artery 
might  be  the  better  controlled.  Spence 
advised  that  the  anterior  angle  should  be 
raised  first,  the  better  to  control  the  sub- 
clavian artery.  MacCormac  advises  that  the  clavicle  be  divided  with  a  fine 
saw  just  internal  to  the  conoid  ligament,  "  for  then  time  is  not  lost  in  detach- 
ing the  outer  extremity  of  the  clavicle  from  its  connection  with  the  scapula." 
All  danger  of  haemorrhage  during  the  operation  is  easily  obviated  by  pres- 
sure on  the  subclavian  artery  above  the  clavicle  by  means  of  a  short  crutch 
or  a  large  key  (Vogel),  also  by  direct  pressure  on  the  subclavian  after  the 
anterior  angle  of  the  scapula  is  elevated. 

The  Operation  of  Excision  of  the  Body  of  the  Scapula  (Fig.  388). — Make 
an  incision  the  whole  length  of  the  spine,  a,  i  ;  begin  a  second  incision  at 
the  posterior  superior  angle  and  carry  it  along  the  posterior  border  of  the 
bone  to  the  inferior  angle,  c,  d ;  dissect  the  resulting  triangular  flaps  from 
their  corresponding  fossas,  carefully  avoiding  the  suprascapular  artery  and 
nerve ;  saw  through  the  acromion  process  close  to  the  body ;  divide  the  mus- 
cles attached  to  the  anterior  and  superior  borders  of  the  scapula ;  raise  the 
bone  upward  and  saw  through  the  angle  just  behind  the  coracoid  process ; 
turn  the  bone  outward  and  sever  its  posterior  connections  with  a  knife  or 
strong  scissors. 

The  acromion  process  and  angles  of  the  scapula  may  be  removed  sepa- 
rately. To  remove  the  former  make  an  incision,  which  is  curved  if  necessary, 
along  its  upper  border,  expose  the  process,  divide  its  muscular  attachments, 
and  with  a  bone  forceps  sever  and  remove  the  desired  amount  of  bone. 
This  process  can  also  be  removed  by  making  a  curved  or  crucial  incision 
over  it,  exposing  its  upper  surface,  dividing  the  muscular  attachments,  dis- 


FiG.  388. — Excision  of  scapula,  f,  g. 
Subspino-glenoid  excision,  e,  c,  /. 
Retro-coraco-glenoid  excision. 


OPERATIONS  ON  BONES. 


383 


articulating  the  clavicle,  and  removing  the  requisite  amount  of  its  structure 
with  a  chain  saw. 

To  remove  an  angle  make  a  V-shaped  incision  over  it,  dissect  off  the  flaps, 
separate  the  muscles  from  the  bone,  and  sever  the  exposed  portion  with  the 
bone  forceps.    Chalot  favors  removal  of  larger  portions  (Fig.  388,  e,f,g). 

The  Operation  of  Subperiosteal  Excision  of  the  Scapula  (Oilier,  Fig. 
389). — Make  an  incision  from  the  outer  extremity  of  the  acromion  process 
along  the  spine  of  the  scapula  to  its  posterior  border,  a,  h.  Make  a  second 
incision  from  the  posterior  superior  angle  of  the  scapula  along  its  posterior 
border,  crossing  the  former  incision  to  the  inferior  angle,  c,  b,  d.  Sever  the 
muscular  attachments  to  the  acromion  process  and  spine ;  divide  the  peri- 
osteum at  the  posterior  border  of  the  scapula  between  the  attachments  of  the 
rhomboideus  major  and  infraspinatus  muscles  and  separate  it  from  the  infra- 
spinous  fossa ;  remove  the  muscular  attachments  of  the  superior  border  of 
the  scapula.  The  periosteum  is  then  raised  from  the  supraspinous  fossa, 
being  careful  not  to  injure  the  suprascapular  vessels,  as  they  pass  in  close 
contact  with  the  suprascapular  notch  ;  cut  the  remaining  muscles  attached  to 
the  borders  of  the  scapula,  closely  hugging  the  bone  ;  raise  the  bone  upward 
by  its  inferior  angle,  denude  the  subscapular  fossa,  leaving  the  periosteum 
connected  with  the  subscapular] s  muscle  ;  liberate  the  posterior  border,  allow- 
ing the  cartilaginous  portion  to  remain  when  present.  Turn  the  bone  up- 
ward and  forward,  remove  the  remaining  periosteum  from  its  under  sur- 
face up  to  the  neck  of  the  scapula,  and  divide  the  bone  at  the  neck  with  the 
chain  saw.  If  the  extent  of  the  disease  will  not  permit  the  sawing  at  this 
situation,  the  neck  can  be  enucleated,  leav- 
ing the  ligaments  connected  with  the  peri- 
osteum. 

Excision  of  the  Gletioid  Angle  of  the 
Scapula. — This  operation  is  only  applicable 
to  those  conditions  of  injury  or  disease  that 
are  limited  to  the  articular  surface  of  the 
glenoid  angle  of  the  scapula.  If  a  pene- 
trating wound  be  present  its  course  should 
be  followed  to  reach  the  bone ;  if  not,  then 
a  curved  incision  is  made  around  the  pos- 
terior border  of  the  acromion  process,  divid- 
ing the  fibers  of  the  deltoid  and  exposing 
the  posterior  and  upper  surface  of  the  joint 
(Fig.  390,  a).  Commencing  at  the  center  of 
this  one,  a  second  incision  is  then  made, 
from  the  upper  margin  of  the  glenoid  cavity,  and  passing  downward  through 
the  deltoid  in  the  direction  of  its  fibers,  also  through  the  capsule  upon 
the  center  of  the  greater  tuberosity,  going  between  the  tendons  of  the 
supra-  and  infraspinatus  muscles.  Open  the  wound  widely  by  means  of 
retractors  and  divide  the  tendons  of  the  heads  of  the  biceps  and  triceps  above 
and  below  the  cavity  at  their  respective  origins ;  separate  the  periosteum 
from  around  the  neck  of  the  scapula,  if  possible,  leaving  the  attachments 


Fig.  389.— Subperiosteal  excision  of 
scapula. 


384 


OPERATIVE  SURGEET. 


of  the  capsular  ligament.     Out  through  the  exposed  bone  with  a  saw,  and 

remove  the  fragment  carefully  to  avoid  injury  to  the  periosteum. 

The  Remarhs. — Excision  of  a  considerable  amount  of  the  bone  is  quite 

as  fatal  as  the  complete  excision,  owing  to  the  greater  difficulty  of  catching 

the  bleeding  points  in  the  former,  which  promptly 
retract  between  the  bone  and  adjacent  muscles, 
and  also  to  the  comparatively  greater  injury  in- 
flicted by  reason  of  the  limited  field  of  action. 
The  glenoid  cavity  and  the  points  of  insertion  of 
important  muscles,  as  the  acromion  and  the  cora- 
coid  processes,  should  be  preserved  when  practi- 
cable, for  manifest  reasons. 

If  the  head  of  the  bone  be  placed  beneath  the 
end  of  the  clavicle,  and  the  capsule  connected  with 
the  upper  end  of  the  humerus  be  sewed  to  the 
under  surface  of  the  deltoid  muscle,  much  gain  in 
the  use  is  thus  accomplished. 

The  After  -  treatment.  —  Complete  drainage 
must  be  maintained  with  the  patient  in  the  re- 
cumbent posture,  and  with  the  arm  and  shoulder 
supported  in  a  comfortable  position.  After  heal- 
ing is  completed  the  extremity  should  be  supported 
by  a  sling  until  the  tone  of  the  parts  is  sufficiently 
restored  to  meet  this  indication  unaided. 

The  results  of  these  operations  are  good.  Of 
sixty-six  cases  of  complete  excision  fourteen  died. 
The  rate  of  mortality  is  greater  when  removed 
for  traumatic  causes  than  for  disease.  Astonish- 
ingly good  use  of  the  limb  frequently  follows, 

especially  in  the  performance  of  those  requirements  not  connected  with  the 

function  of  the  deltoid  muscle. 


Fig.  390. — Incisions  in  exci- 
sions of  angle  of  scapula 
and  head  of  humerus. 


EXCISIONS    OF   THE    UPPEE    EXTEEMITT. 

Excision  of  the  Humerus. — The  humerus  can  be  removed  entirely  or  in 
part,  as  circumstances  demand.  This  operation  is  done  for  the  relief  of  old 
dislocations,  caries,  necrosis,  gunshot  injuries,  arthritis,  malignant  disease, 
etc. 

The  Anatomical  Points. — In  excisions  of  this  bone  the  insertions  of  the 
muscles  acting  upon  the  upper  end,  the  course  of  the  superior  profunda  and 
circumflex  arteries,  the  relations  of  the  circumflex,  musculo-spiral,  and  ulnar 
nerves,  the  points  of  insertion  of  the  ligaments  of  the  joints,  together  with 
the  connections  of  the  important  muscles,  must  be  carefully  considered  be- 
fore beginning  the  operation. 

The  bicipital  groove  looks  forward  at  all  times  in  the  normal  arm,  and 
with  the  arm  at  the  side  and  forearm  supinated  it  corresponds  in  direction 
with  the  palm.  The  surgical  neck  of  the  humerus  is  located  between  the 
tuberosities  above  and  the  insertions  of  the  tendons  of  the  pectoralis  and  teres 


OPERATIONS  ON  BONES. 


385 


major  and  the  latissimus  dorsi  muscles  below.  The  circumflex  nerve  and 
posterior  circumflex  vessels  pass  around  the  surgical  neck  at  a  point  aljout 
one  inch  above  the  center  of  the  deltoid.  About  one  fourth  of  the  epi- 
physeal junction  of  the  upper  end  is  subperiosteal  and  located  at  the  outer 
aspect;  the  remainder  is  subcartilaginous  and  intracapsular  (Fig.  391). 

The  Operation  of  Excision  of  the  Upper  End  of  the  Humerus — Vertical 
Incision  (Langenbeck). — Place  the  patient  upon  the  back  close  to  the  edge 
of  the  table;,  with  the  shoulders  raised.  Make  an  incision  about  four  inches 
in  length  downward  from  the  anterior  border  of  the  acromion  process, 
close  to  its  articulation  with  the  clavicle,  in  the  line  of  the  bicipital  groove 
(Fig.  392,  &).  The  bone  at  this  region  is  quite  superflcial.  Liberate  the 
long  head  of  the  biceps  tendon  from  the  groove  by  carrying  the  point  of 
the  knife  upward  in  the  groove  at  the  outer  side  through  the  capsule  to 
the  acromion  and  raise  the  tendon  out  of  the  groove  (Fig.  393) ;  rotate  the 
arm  outward  and  divide  the  subscapularis  tendon  and  inner  portion  of  the 
capsule;  then  rotate  the  arm  inward  and  cut  the  external  rotators  at  their 
insertions,  also  the  posterior  portion  of  the  capsule  (Fig.  394)  ;  force  the 
head  of  the  bone  through  the  opening  in  the  soft  parts,  seize  it  with  a 
strong  pair  of  bone-holding  forceps,  divide  the  inferior  portion  of  the  cap- 
sule, and  remove  the  head  of  the  bone  with  a  chain  saw,  Gigli-Haertel,  or 


Fig.  391.—^.  Epiphysis.  B,  C.  Attach- 
ment of  capsular  ligament.  Epipiiyseal 
junction  noted. 


Fig.  392. — Incisions  in  excisions  of  end  of 
humerus,  a.  Baudens,  Hueter,  Oilier, 
h.  Langenbeck.    c.  U-shaped. 


a  small  straight  saw  (Fig.  395),  carefully  avoiding  the  circumflex  vessels  and 
nerves. 

The  Operation  of  Excision  of  the  Upper  End  of  the  Humerus — Oblique 
Incision  (Baudens,  Hueter,  Oilier). — Place  tlie  patient  as  in  the  preceding 
operation;  make  an  incision  from  the  outer  side  of  the  tip  of  the  coracoid 
process  downward  and  outward  along  the  anterior  border  of  the  deltoid 
three  or  four  inches  in  length  (Fig.  392,  a) ;  expose  the  coraco-acromial 


386 


OPERATIVE  SURGERY. 


Fig.  393. — Raising  tendon. 


ligament  and  bare  the  capsule  in  the  line  of  the  incision ;  locate  the  biceps 
tendon,  and  divide  the  capsule  at  its  outer  side  from  below  upward;  draw 
apart  the  borders  of  the  wound  and  separate  the  soft  parts  from  the  upper 
end  and  outer  surface  of  the  bone  with  a  knife  as  the  bone  is  rotated  inward ; 

divide  the  insertions  into  the  great  tuberosity  of 
the  supraspinatus,  infraspinatus,  and  teres  minor 
muscles;  clear  the  inner  aspect  in  the  same  way 
as  the  humerus  is  rotated  outward;  locate  the 
lesser  tuberosity;  divide  the  subscapularis  inser- 
tion and  the  attachment  of  the  capsule  beyond; 
flex  the  elbow  and  displace  the  biceps  tendon  in- 
ward; cause  the  head  of  the  bone  to  project 
through  the  wound ;  seize  the  extremity  with  bone- 
holding  forceps  and  sever  it  with  a  saw. 

The  Comments. — Good  drainage  should  be 
secured  by  posterior  puncture,  if  need  be.  The 
tuberosities  should  be  saved  when  possible,  on  ac- 
count of  their  important  muscular  insertions.  In 
children  carefully  avoid  injury  of  the  epiphyseal 
cartilage,  if  practicable.  Remove  sharp,  bony  points 
and  borders  from  the  sawed  end  of  the  bone,  so  that  they  can  cause  no  injury 
to  the  axillary  vessels  and  nerves. 
A  V-  or  the  U-shaped  (Fig.  392, 
c)  incision  should  not  be  prac- 
ticed when  the  vertical  or  oblique 
ones  can  be  utilized,  as  the  former 
may  needlessly  damage  the  del- 
toid muscle.  The  circumflex 
nerve  must  be  carefully  avoided, 
because  division  or  bruising  will 
destroy  or  impair  its  function. 

MacCormac  suggests  exci- 
sion through  a  posterior  inci- 
sion, when  the  bone  need  not  be 
divided  below  the  tuberosities. 

The  Operation. — With  the 
patient  placed  on  the  sound  side, 
the  arm  abducted  and  rotated 
outward  so  that  the  outer  con- 
dyle looks  backward,  and  the 
forearm  flexed,  make,  from  the 
angular  projection  of  the  acro- 
mion downward  through  the 
posterior  part  of  the  deltoid  and 
through  the  capsule,  an  incision 
four  inches  in  length  (Fig.  390, 
6);  expose  the  great  tuberosity 


Fig.  394. — Attachments  to  tuberosities  of  hume- 
rus, a.  Teres  minor  muscle,  b.  Infraspi- 
natus muscle,  c.  Supraspinatus  muscle,  d. 
Subscapularis  muscle.  /.  Tendon  of  long 
head  of  bice{)S  muscle  in  the  groove,  ff.  La- 
tissimus  dorsi  tendon. 


OPERATIONS  ON  BONES. 


387 


and  the  bicipital  groove,  removing  the  muscles  from  the  former  at  their  at- 
tachment; rotate  the  arm  outward  still  farther,  raising  the  periosteum  and 
capsule  till  the  bicipital  groove  is  reached ;  dislodge  the  tendon  and  raise  it 
upward ;  rotate  the  arm  strongly  inward,  bringing  the  insertion  of  the  sub- 
scapularis  into  view,  and  separate  it  from  its  attachment ;  push  the  head  of 
the  bone  through  the  wound  and  separate  the  remaining  soft  parts  as  the 
arm  is  rotated  alternately  outward  and  inward;  extrude  still  farther  the 
head  of  the  bone  and  saw  it  off. 

The  Comments. — The  circumflex  nerve  (Fig.  404)  will  be  divided  in  this 
method  unless  great  caution  be  exercised,  nor  is  ample  room  afforded. 

The  Operation  of  S  lib  periosteal  Excision  of  Head  of  Humerus  (Langen- 
beck). — Expose  the  i)icipital  groove  and  split  up  the  capsular  ligament  as  in 
the  non-periosteal  operation  (Fig.  392,  h).  Divide  and  raise  the  periosteum 
from  the  inner  border  of  the  bicipital  groove,  passing  inward  and  separating 
it  together  with  the  subscapularis  and  the  fibrous 
capsule  from  the  lesser  tuberosity.  Eotate  the 
humerus  outward  and  complete  the  separation  to 
the  required  extent  with  the  elevator  and  knife; 
rotate  the  humerus  inward,  displace  the  tendon 
of  the  biceps  to  the  inner  side  of  the  head  of  the 
humerus,  and  separate  the  periosteum  from  the 
latter  in  connection  with  the  capsule  and  the  in- 
sertions of  the  external  rotators,  being  very  care- 
ful not  to  sever  the  connection  of  the  periosteum 
with  the  bone  below.  The  forcing  of  the  head 
of  the  bone  through  the  external  opening  is  prac- 
tically impossible  without  destroying  the  peri- 
osteal connections.  It  is  necessary,  therefore,  to 
divide  the  bone  with  a  chain  or  narrow-bladed 
saw  without  displacement. 

Subperiosteal  excision  is  practiced  through 
the  oblique  incision  of  Baudens  aud  others  (Fig.  393,  a)  with  almost  equal 
facility  to  that  of  the  vertical  one.  After  exposure  of  the  capsule  and  locali- 
zation of  the  biceps  tendon,  the  former  is  divided  upward  vertically  at  the 
outer  side  of  the  tendon.  The  upper  end  of  the  bone  is  then  freed  of  its 
periosteum  and  muscular  attachments  to  the  proper  distance  with  a  rugine, 
the  humerus  being  rotated  outward  and  inward  as  before  described,  to  meet 
the  requirements  of  the  procedure. 

The  Comments. — The  removal  of  tlic  periosteum  along  with  muscular 
attachments  is  quite  difficult,  and  must  bo  carefully  practiced,  especially  in 
the  latter  instances,  to  prevent  destruction  of  tissues  from  too  vigorous  effort. 
Subperiosteal  excision  should  be  practiced  whenever  it  is  possible  to  do  so,  since 
the  outcome  obtained  is  superior  to  that  of  the  less  conservative  methods. 

Partial  removal  of  the  upper  extremity  of  the  humerus  is  often  necessary 
on  account  of  disease  or  injury.  The  variety  and  extent  of  the  incisions 
necessary  to  reach  the  part  must  be  governed  by  the  amount  of  the  disease, 
which  may  be  so  great  as  to  demand  the  U-shaped  flap  (Fig.  39.2,  c). 


Fig.  395. — Sawing  head  of 
humerus. 


388  OPERATIVE  SURGERY. 

The  Operation  of  Excision  of  the  Head  of  the  Humerus  (Senn). — This 
plan  of  procedure  places  the  scar  resulting  from  the  operation  beneath  the 
protecting  prominence  of  the  shoulder  and  provides  free  access  to  every  por- 
tion of  the  joint  and  the  contiguous  parts. 

The  Operation. — Form  a  semilunar  flap  of  integument  and  fascia,  begin- 
ning over  the  coracoid  process  and  going  with  a  gentle  curve  downward 


/ 

c 

...      /  -  ' 

i 

/ 

/ 

/ 

A 

I 
1 

/I' 

/      1 
/       - 

•^  ■ 

\ 

\ 

\ 

Fig.  896. — Senn's  method  of  resection  Pig.    397. — Sean's  method  of  resection, 

of    shoulder   joint.     External   inci-  Division    of    acromion.      Reflection 

sion,  flap  reflected,  and  saw  applied  downward  of  fragment  with  deltoid 

over  base  of  acromion.  muscle.     Head  of  humerus  resected. 


'\ 
) 

; 

/ 

/ 

J 

/ 

/' 

1 

/ 

/ 

\ 
\ 

/ 

'i 

Fig.  398. — Temporarily  detached  aero-  Fig.  399. — Operation  completed, 

mion  replaced  and  fastened  in  posi- 
tion with  strong  catgut  sutures. 


OPERATIONS  ON  BONES.  389 

and  outward  across  the  lino  of  junction  of  the  upper  and  lower  halves  of 
the  deltoid  muscle^,  thence  with  a  similar  curve  upward  and  backward  to 
the  posterior  border  of  the  axillary  space  to  a  point  opposite  the  beginning; 
dissect  up  and'  reflect  the  semilunar  flap  to  the  base  of  the  acromion  pro- 
cess; saw  transversely  (Fig.  396)  through  this  process,  detach  downward 
the  fragment  along  with  its  deltoid  connections,  thereby  freely  exposing 


Acromio- 
.      clavicular 
I     articulatioiL 


Fig.  400. — Koclier's  method  of  exciMoii  ui'  the  shoulder  joint  from  behind.     Muscles 
divided  and  acromion  process  exposed  for  sewing. 

(Fig.  397)  the  capsular  ligament;  open  the  capsule  and  examine  the  joint 
cavity  to  determine,  in  case  of  disease,  the  direction  and  requisite  extent  of 
the  operation;  perform  a  complete  arthrectomy  if  the  disease  be  limited  to 
the  soft  structures,  dislocating  the  head  of  the  humerus  in  different  direc- 
tions to  facilitate  the  procedure;  resect  the  head  of  the  humerus  if  suffi- 
ciently diseased,  and  remove  it  to  make  easier  any  steps  of  subsequent 
arthrectomy;  remove  all  diseased  tissues,  thoroughly  cleanse  the  wound, 
introduce  drainage  if  needed,  replace  the  acromion  process  and  suture  it 
in  position  with  strong  chromicized  catgut  (Fig.  398)  ;  unite  the  divided 
portions  of  the  deltoid  muscle  with  buried  sutures;  return  the  cuta- 
neous flap,  suturing  it  in  place  in  the  usual  manner  (Fig.  399) ;  apply 
abundant  aseptic  dressing  to  the  wound  and  confine  the  arm  to  the  side  of  the 
chest  by  means  of  a  light  plaster-of-Paris  bandage.  If  the  exposure  of  the 
joint  be  made  for  cure  of  irreduL'il)le  dislocation,  the  head  of  the  hmnerus 
can  be  located  as  soon  as  the  deep  flap  is  turned  down  and  the  causes  of 
26* 


390 


OPERATIVE  SURGERY. 


the  resistance  to  reduction  determined  and  removed  by  division  or  other 
means,  and  the  head  of  the  bone  is  restored  to  its  proper  place.  In  these 
instances  drainage,  as  a  rule,  is  not  employed. 

The    Comment. — Bardenheuer's    incision    is    made    directly    over    and 
through  the  acromion  process,  thus  placing  the  scar  in  an  exposed  situation. 

Kocher  practices  excision  of  the  shoulder  joint  from  iehind  through  a 
curved  incision  carried  from  and  into  the  acromio-clavicular  joint  over  the 
top  of  the  shoulder  along,  then  across  the  acromion  corresponding  to  its 
root,  severing  the  corresponding  insertion  of  the  trapezius,  thence  down- 
ward in  a  curved  direction  toward  the  posterior  fold  of  the  axilla,  divid- 
ing the  dense  fascia  and  exposing  the  posterior  border  of  the  deltoid  to  a 
point  about  an  inch  and  three  quarters  above  the  fold  (Fig.  400).  He 
frees  the  infraspinous  muscle  with  the  finger  from  the  outer  border  of  the 
spine  and  root  of  the  acromion  process,  detaches  the  supraspinous  muscle 
from  the  spine  with  a  blunt  director,  so  as  to  permit  the  finger  to  pass  from 
above  beneath  the  root  of  the  acromion.  He  then  chisels  obliquely  through- 
the  acromion  at  the  inner  limit  of  the  roots  and  pushes  the  fragment  (Fig. 


Biceps  tendon. 


Ant.  sawn  surface -v 
of  spine  of 
scapula. 

Deltoid  m 
Incision  in  capsule 
along  post,  edge 
of  biceps  tendon 
and  at  upper 
border  of  supra- 
spin.  m. 


8upra.spinatns  m. 


Sawn  surface  of 
spine  of  scapula. 


Infraspinatus  m. 


Fig.  401. — Kocher's  method  of  excision  of  shoulder  joint  from  behind.     Flap  reflected 
and  the  capsule  excised  behind  the  long  tendon  of  the  biceps. 

401)  over  the  head  of  the  humerus  along  with  the  attached  deltoid,  thus 
exposing  the  upper  and  posterior  aspects  of  the  head  of  the  bone,  revealing 
the  muscles  and  tendons  associated  therewith.  The  arm  is  then  rotated 
outward  and  curved  forward  and  an  incision  is  made  down  to  the  bone, 
commencing  at  the  upper  part  of  the  posterior  lip  of  the  bicipital  groove, 
passing  upward  through  the  capsule  along  the  anterior  edge  of  the  inser- 


OPERATIONS  OX  BONES. 


391 


tion  of  the  external  rotators  over  the  uppermost  part  of  the  head,  exposing 
the  tendon  of  the  biceps  to  its  point  of  origin  (Fig.  402).  The  insertions 
of  the  external  rotators  are  now  exposed  from  the  great  tuberosity  and 
drawn  backward,  the  biceps  tendon  is  raised  from  its  groove  and  drawn 
forward,  exposing  the  joint  cavity  to  free  inspection  and  to  the  relief  of 
such  radical  or  conservative  steps  as  may  be  advisable. 

The  Comments. — The  view  thus  afforded  is  obtained  without  damaging 
any  important  functional  muscles  of  the  joint,  and  without  injury  to  the 


ine  of  scapula 

■Supraspinatua  m. 


Infraspinatus  m. 
/Post,  edge  of 
I  capsule  de- 
\  tached  from 
I  the  greater 
V    tuberosity. 


Fig.  402. — Kocher's  method  of  excision  of  the  shoulder  joint  from  behind.  The  head  of 
the  humerus  exposed  and  ready  for  displacement  upward  for  complete  excision  if 
required. 

circumflex  nerve  and  vessels,  if  reasonable  care  is  exercised.  If  the  head 
of  the  bone  be  removed,  increased  observation,  especially  below,  is  secured. 
This  plan  offers  special  opportunity  to  examine  and  treat  conditions  refer- 
able to  the  posterior  part  of  the  joint. 

The  Operation  of  Arthrotomy  for  Irreducible  Dislocation  of  the 
Humerus. — This  unfortunate  condition  may  happen  with  and  without  frac- 
ture of  the  upper  end  of  the  humerus,  and  the  latter  may  occur  primarily 
or  be  secondary  to  efforts  at  reduction.  In  all  instances  of  dislocation,  rea- 
sonable attempts  at  bloodless  reduction  by  manipulative  methods  should  be 
practiced.  The  operation  is  indicated  either  before  decided  inflammatory 
changes  and  extravasation  have  ensued,  or  at  a  period  immediately  fol- 
lowing their  practical  cessation.  In  instances  of  fracture,  the  earlier  period 
is  apt  to  be  the  better  time  to  effect  reduction.  "Whenever  approach  for  pur- 
poses of  reduction  can  be  made  without  invading  the  cavity  of  the  joint,  or 
going  through  ruptured  structures,  the  earlier  the  endeavor  is  made  the 
better. 


392 


OPERATIVE  SURGERY. 


The  Operation. — Expose  freely  the  capsule  of  the  joint  through  an  an- 
terior incision  of  not  less  than  three  inches  in  length,  made  in  the  line 
of  the  bicipital  groove ;  draw  apart  the  borders  of  the  wound,  remove  from 
the  field  thus  disclosed  all  extravasated  blood  and  carefully  examine  the 
structures  concerned,  and  also  the  patient,  with  the  idea  of  determining  if 
the  head  of  the  bone  or  the  glenoid  cavity  be  much  damaged ;  also  the  need 
of  extended  dissection  and  the  ability  to  restore  and  retain  in  place  with 
useful  outcome  the  dislocated  head;  if  the  vitality  be  ample  to  obviate 
necrosis,  and  if  the  condition  of  the  patient  justifies  prolonged  and  pro- 
found efforts  at  restoration ;  also,  consider  if  the  capacity  for  complete  and 
continued  asepsis  be. assured.  Should  one  or  more  of  these  propositions 
oppose  reduction  with  practical  emphasis,  then  prompt  resection  should  be 
considered,  whether  fracture  be  present  or  not;  if  otherwise,  efforts  at  re- 
duction should  as  promptly  be  made.  In  the  absence  of  fracture,  efforts  at 
restoration  will  demonstrate  the  special  structures  that  oppose  return  of  the 
head  to  the  glenoid  cavity.  These  structures  in  turn  should  be  partly  or 
completely  severed,  as  circumstances  require,  or  their  opposing  influences 
obviated  by  manipulations  of  the  arm  and  of  the  tissues,  by  proper  tractile 
agents.  The  tendon  of  the  long  head  of  the  biceps,  the  subscapularis,  the 
external  rotators  and  portions  of  the  capsular  ligament  are  singly  or  vari- 
ously combined  prominent  agents  of  obstruction  to  return. 

In  the  presence  of  fracture  the  loss  of  fulcrumage  due  to  fracture  of  the 
bone  adds  its  potent  hindrance  to  that  of  the  restraining  agents  already, 
cited.  Fulcrumage  is  supplied  in  a  lesser  degree  than  natural  by  bone  for- 
ceps (Fig.  375,  h),  the  McBurney  hook  (Fig.  403),  and  similar  agents,  sup- 


FiG.  403. — The  McBurney  hook  for  supplying  fulcrumage  in  dislocation  with  fracture. 

plemented  by  digital  manipulation,  aided  by  prying  agents  directly  applied. 
No  definite  technique  of  reduction  can  be  established,  the  indications  being 
met  as  the  varying  circumstances  of  cases  arise.  After  reduction,  the  frag- 
ments of  bone  should  be  sutured  together,  the  capsule  repaired,  ligaments 
united  and  muscular  insertions  fastened  in  place,  by  sewing  with  kangaroo 
tendon  or  chromicized  catgut.  The  wound  should  be  drained  and  dress- 
ing held  in  position,  and  the  arm  confined  to  the  side  by  several  turns  of 
plaster-of-Paris  bandage. 

Careful  observation  of  the  temperature  should  be  made  to  note  the 
approach  of  any  infiammatory  manifestations;  when  noted,  the  dressings 
should  be  promptly  removed  and  the  wound  examined  for  hidden  infection. 


OPERATIONS  ON  BONES.  393 

The  Remarks. — The  anterior  incision  is  better  than  the  posterior  or  the 
axillary.  The  latter  affords  easy  resection,  but  is  objectionable  in  reduction, 
especially  with  fracture.    Various  anatomical  associations  also  oppose  it. 

Senn's  incision  is  a  commendable  one  for  the  purpose.  Consult 
Souchon's*  able  and  finished  article  on  Operative  Treatment  of  Irreduci- 
ble Dislocations  of  the  Shoulder-Joint,  Eecent  or  Old,  Simple  or  Com- 
pound, if  possible,  before  taking-  final  action. 

The  After-treatment.— Early,  careful  and  persistent  passive  motion, 
massage,  electric  stimulation  and  gymnastic  exercise  should  be  practiced. 

The  BesuUs.— In  dislocation  with  fracture,  digital  manipulation  suc- 
ceeded in  restoring  the  parts  in  36  of  80  cases  (McBurney).  According 
to  Souchon,  "mere  improvement"  is  noted  in  5  per  cent  of  reductions 
and  in  28  per  cent  of  resections.  "  Fair  results  "  in  16  per  cent  of  the 
former  and  in  16  per  cent  of  the  latter.  "  Good  results  "  in  50  per  cent 
of  the  former  and  42  per  cent  of  the  latter;  "  death-rate,"  10  per  cent  in 
reductions  and  12  per  cent  in  resections. 

The  Operation  for  Habitual  Dislocation  of  the  Humerus.— Gev&tev, 
Eicard,  Burrell  and  others  have  cured  the  above  infirmity  by  removing  the 
redundancy  of  the  anterior  part  of  the  capsular  ligament  of  the  shoulder 
joint  and  closing  the  wound  with  sutures.  The  following  is  the  operative 
method,  as  practiced  by  Burrell.  f 

The  Operaiion. — Place  the  patient  on  the  back  with  the  arm  slightly 
abducted ;  make  an  incision  from  the  coracoid  process  downward  and  out- 
ward, along  the  groove  formed  by  the  junction  of  the  deltoid  and  pectoralis 
major  muscles  (avoiding  the  cephalic  vein),  to  below  the  upper  border  of 
the  tendon  of  insertion  of  the  pectoral  muscle ;  draw  the  vein  aside,  separate 
the  muscles  from  each  other,  exposing  the  coraco-brachialis,  short  head  of 
the  biceps  and  the  upper  part  of  the  tendon  of  the  pectoralis  major  below; 
avoid  the  acromio-thoracic  artery,  divide  the  upper  three  fourths  of  the 
tendinous  insertion  of  the  pectoralis  major,  retract  the  muscle  so  as  to  expose 
the  head  and  much  of  the  bone.  After  the  tendon  of  the  coraco-brachialis 
and  the  short  head  of  the  biceps  are  cleared,  and  the  wound  extended  quite 
up  to  the  coracoid  process,  rotate  the  arm  externally,  letting  it  fall  backward, 
thus  revealing  the  insertion  of  the  subscapularis  stretched  over  the  head  of 
the  bone,  the  upper  portion  of  which  tendon  is  at  once  divided ;  abduct  the 
arm  to  an  angle  of  45  degrees,  and  press  the  head  of  the  bone  backward, 
thus  relaxing  the  front  portion  of  the  capsule;  grasp  with  three-pronged 
forceps  the  loose  part  of  the  front  of  the  capsule  and  insert  through  this 
portion  with  a  curved  needle  three  sutures,  placed  so  as  to  permit  of  exci- 
sion from  the  capsule  of  a  portion  three  quarters  of  an  inch  in  length  and 
three  eights  of  an  inch  in  width ;  tie  the  sutures  firmly,  thus  shortening  and 
tightening  the  capsule ;  irrigate,  dry  and  close  the  wound  in  the  usual  way ; 
apply  aseptic  dressings  and  fix  the  arm  to  the  side,  with  the  hand  across 
the  chest. 

The  Results. — Several  cases  are  reported  with  satisfactory  results. 

*  Transactions  of  the  American  Surgical  Association,  vol.  xv,  1897. 
f  Transactions  of  the  American  Surgical  Association,  vol.  xv,  1897. 
37 


394 


OPERATIVE  SURGERY. 


The  Operation  of  Excision  of  the  Shaft  of  the  Humerus. — In  this  opera- 
tion, unless  great  caution  is  observed,  the  musculo-spiral  nerve  and  the  supe- 
rior profunda  artery  will  be  injured  in  their  course  along  the  musculo-spiral 
groove,  as  will  also  the  circumflex  nerve  and  vessels,  if  the  incision  be  ex- 
tended (Fig.  404)  too  far  upward.  The  upper  portion  of  the  shaft  is  easily 
exposed  by  making  an  incision  of  sufficient  length  through  the  outer  surface 
of  the  deltoid,  commencing  at  its  lower  third  and  dividing  it  carefully  up- 
ward, to  avoid  the  circumflex  nerve  and  artery.  The  bone  denuded  of  its 
periosteum  is  then  removed,  or,  should  there  be  a  morbid  growth  connected 
with  it,  the  bone  and  tumor  should  be  removed  together.    If  the  lower  por- 


FiG.  404. — Musculo-spiral  and  circumflex 
nerves. 


Fig.  405. — Relation  of  ulnar  nerve  to  elbow 
joint,  a.  Inner  condyle  of  humerus.  6. 
Ulnar  nerve,     c.  Olecranon  process. 


tion  of  the  shaft  is  to  be  operated  upon,  make  the  incision  along  the  outer 
border  of  the  brachialis  anticus  muscle,  carefully  avoiding  the  musculo-spiral 
nerve.     Expose  the  bone  and  remove  it  as  before. 

The  Excision  of  the  Lower  Extremity  of  the  Humerus. — The  relation  of 
the  ulnar  nerve  (Figs.  405,  h,  and  223,  J)  to  the  internal  condyle,  a,  and  of 
the  brachial  artery  to  the  anterior  surface  must  not  be  forgotten.  Make  an 
incision  on  the  posterior  and  external  surface  of  sufficient  length  to  thor- 
oughly expose  the  bone;  elevate  the  periosteum  and  divide  the  bone  with  a 
saw;  pull  the  upper  end  of  the  fragment  downward  and  disarticulate  it 
from  without  inward. 


OPERATIONS  ON  BONES.  395 

If  it  be  necessary  to  remove  the  entire  huvien.is,  make  incisions  as  if  to 
remove  the  upper  and  lower  portions,  observing  the  same  precautions  rela- 
tive to  the  anatomy  of  these  parts  as  before  expressed.  The  musculo-spiral 
nerve  in  this  operation  is  to  be  cautiously  aveided. 

The  After-treatment. — In  the  preceding  operations  substantially  the 
same  treatment  is  required :  Arrest  the  haemorrhage,  provide  drainage,  close 
the  lips  of  the  wound,  envelop  the  entire  limb  with  antiseptic  dressing,  and 
place  it  upon  a  splint  or  a  triangular-shaped  axillary  pad,  affording  an  easy 
support  at  the  proper  angle.  Thereafter  redressing  is  practiced  in  the 
manner  and  with  the  frequency  required.  As  early  as  practicable  passive 
motion  of  the  joints  of  the  extremity,  with  massage  and  electricity,  are 
carried  into  effect.  Extension  with  a  weight  is  often  necessary  during  the 
early  healing  process  in  order  to  maintain  the  limb  at  a  suitable  length  and 
to  avoid  anchylosis. 

The  Results. — The  results  depend  much  upon  the  nature  of  the  in- 
jury or  of  the  disease,  the  period  of  the  operation,  and  the  employment  of 
antiseptics.  Of  984  cases  done  before  asepsis,  856  were  done  for 
gunshot  injury,  with  a  mortality  of  36.68  per  cent,  and  128  for  disease, 
22.77  per  cent  of  which  died;  (Culberston)  of  164  cases  done  under  asep- 
sis for  all  causes,  12.1  per  cent  died.  In  nearly  all  cases  the  limbs  were 
useful. 

Excision  of  the  Elbow  Joint. — Excision  of  the  elbow  joint  consists  in  the 
removal  of  the  articular  surfaces  and  more  or  less  of  the  shafts  of  the  three 
bones  composing  it. 

The  Anatomical  Points. — While  the  anatomical  points  associated  with 
the  elbow  joint  are  numerous,  yet  the  really  essential  ones  can  be  quite 
briefly  stated.  The  time  of  union  and  the  lines  of  junction  of  the  epiph- 
yses should  be  carefully  noted  in  order  if  possible  to  avoid  disturbance  of 
the  epiphyseal  structure.  The  internal  condyle  is  longer,  thinner,  and  more 
prominent  than  the  outer.  The  olecranon  and  coronoid  processes  and  the 
tubercle  of  the  radius  afford  attachment  to  important  muscles,  and  should 
therefore  be  preserved  when  possible.  The  triceps  is  inserted  into  the  ole- 
cranon and  the  periosteum  and  is  continuous  with  the  fascia  of  the  forearm 
posteriorly.  The  biceps  through  the  agency  of  the  bicipital  fascia  alone 
can  flex  and  pronate  the  forearm.  Through  the  influence  only  of  the 
tendon  of  insertion  flexion  and  supination  are  accomplished.  The  ulnar 
nerve  lies  in  the  groove  between  the  olecranon  process  and  the  internal 
condyle  close  to  the  bone  in  a  fibrous  environment  of  its  own  (Figs.  223,  J, 
and  405,  &).  The  supinator  brevis  should  be  treated  carefully  in  removal 
of  the  head  of  the  radius,  not  alone  for  the  preservation  of  its  own  function, 
but  likewise  for  protection  of  the  posterior  interosseous  nerve  that  passes 
through  it. 

The  Operation  of  Excision  of  the  Elbow  Joint  (Hiiter). — With  the  fore- 
arm extended  make  a  slightly  curved  incision  about  an  inch  in  length  down 
upon  the  tip  of  the  internal  condyle  and  carefully  separate  the  muscular  and 
ligamentous  attacliments  to  the  condyle.  Make  a  second  longitudinal  in- 
cision from  three  to  four  inches  in  length  from  above  the  outer  condyle  to 


396 


OPERATIVE  SURGERY. 


Fig.  406.— Hiiter's 
incision. 


just  below  the  head  of  the  radius  (Fig.  406).    Draw  aside  the  soft  parts  and 

cut  the  external  lateral  and  orbicular  ligaments  (Fig.  407,  ligaments  of  elbow 
joint).  Expose  the  head  and  neck  of  the  radius  and  cut 
off  the  head  with  a  saw  or  bone  forceps.  Separate  the 
capsular  ligament  from  its  attachments  on  the  anterior 
and  posterior  surfaces  of  the  humerus  and  force  the  ex- 
tremity of  the  humerus  out  of  the  external  wound.  This 
movement  admits  of  division  of  the  bone  and  at  the  same 
time  draws  the  ulnar  nerve  from  its  bed  and  away  from 
the  inner  condyle.  Saw  off  the  lower  end  of  the  humerus 
and  carefully  expose  and  remove  the  olecranon. 

The  Operation  of  Subperiosteal  Excision  of  Elbow  Joint 
(Langenbeck). — Beginning  at  a  point  a  little  to  the  inner 
side  of  the  middle  of  the  olecranon  process,  and  about  two 
inches  and  a  half  below  the.  tip,  make  a  longitudinal  in- 
cision toward  the  humerus  down  to  the  bone  about  four 
inches  in  length,  carefully  avoiding  the  ulnar  nerve  (Fig. 
408,  a,  Langenbeck's  incision).     Eemove  the  periosteum 

from  the  portion  of  the  olecranon  process  and  ulna  at  the  inner  side  of 

the  incision.     Separate  by  short  parallel  incisions  the  attachments  of  the 

inner  half   of  the  triceps  tendon  to  the  olecranon   process.      Push  the 

tissues   at   the   internal    condyle,    together 

with  the  ulnar  nerve  (Fig.   410),   inward 

toward  the  tip  of  the  condyle,  and  elevate 

the  periosteum  from  the  inner  condjde  suf- 
ficiently to  separate  the  internal  lateral  liga- 
ments and  the  attachments  of  the  muscles 

from  the  bone  and  leave  them  connected  with 

the  periosteum.     The  liberated  tissues  are 

now  permitted  to  return  to  their  former 

position,  and  the  outer  portion  of  the  tendon 

of  the  triceps  is  drawn  outward  and  discon- 
nected from  the  olecranon  process  by  short 

transverse  incisions,  closely  hugging  the  bone 

and  allowing  it  to  remain  continuous  with 

the  periosteum  which  is  reflected  upon  the 

outer  surface  of  the  olecranon  and  shaft 

of  the  ulna.     Expose  the  external  condyle 

by  separating  the  capsular  ligament  at  its 

attachment  above  the  trochlea  and  capitel- 

lum.     The  tissues,  including  the  detached 

periosteum  and  tendon  of  the  triceps,  are 

separated  well  from  the  bone  by  retractors. 

Flex  the  forearm  and  force  the  extremities  of 

the  bones  through  the  opening ;  saw  off  the 

head  of  the  radius,  then  the  lower  end  of  the 

humerus,  and  finally  the  olecranon  process.  Fig.  407. — Ligaments  of  elbow  joint. 


OPERATIONS  ON  BONES. 


397 


The  Operation  of  Excision  of  the  Elbow  Joint  by  the  H  Shaped  Incision 

(Liston). — Flex  the  elbow  to  an  obtuse  angle,  the  operator  facing  its  poste- 
rior surface;  open  the  capsule  between  the  olecranon  process  and  internal 
condyle  by  a  longitudinal  incision  about  four  inches  in  length  made  along 
the  inner  border  of  the  olecranon  (Fig.  409) ;  dissect  and  draw  the  soft  parts 
over  the  internal  condyle  with  the  thumb  (Fig.  410),  increasing  the  flexion 
gradually  till  the  condyle  is  fully  exposed;  divide  the  internal  lateral  liga- 
ment, extend  the  arm,  and  carry  a  transverse  incision  from  the  point  of 
articulation  of  the  radius  with  the  humerus  directly  across  to  the  center  of 
the  former  incision. 

The  periosteum  on  the  inner  surface  of  the  olecranon  process  and  ulna 
is  raised  and  left  connected  with  the  tendon  of  the  triceps,  which  is  care- 
fully separated  from  the  bone.  Open 
the  flaps  widely  and  divide  the  external 
lateral  ligament,  flex  the  forearm,  and 
the  articular  surfaces  will  separate. 
Seize  and  saw  off  the  lower  extremity 
of  the  humerus,  the  olecranon  process, 
and  finally  the  head  of  the  radius. 

The  Operation  of  Excision  by  the 
Bayonet-shaped  Incision  (Oilier,  Fig. 
408,  h). — The  terminal  portion  of  the 
bayonet  incision  is  vertical,  begins  two 
and  one  half  inches  above  the  line  of 
the  articulation,  and  passes  downward 
between  the  triceps  and  supinator  lon- 
gus  muscles  and  terminates  at  the  tip 
of  the  outer  condyle.  The  middle  or 
oblique  portion  of  the  incision  extends 
from  the  tip  of  the  condyle  downward 
and  inward  to  the  base  of  the  olecra- 
non, thence  along  the  posterior  border 
of  the  ulna  for  one  and  a  half  to  two 
inches.  An  internal  incision  an  inch 
in  length  is  then  made  with  the  center 

at  the  internal  condyle,  the  bone  exposed,  and  internal  lateral  ligament  de- 
tached. The  external  condjde,  olecranon  and  coronoid  processes  and  head  of 
the  radius  are  exposed  in  the  usual  manner,  bones  dislocated  forward,  lower 
end  of  humerus  is  entirely  freed,  and  the  bones  are  severed  with  a  fine  saw. 

The  RemarJis. — It  would  appear  that  the  saving  of  synovial  membrane 
exerts  a  more  conservative  influence  on  the  usefulness  of  the  joint  than  the 
saving  of  bone,  provided,  of  course,  that  the  bony  insertions  of  the  muscles 
acting  directly  on  the  joint  be  respected.  If  the  operation  be  for  trauma- 
tism, remove  the  fragments;  if  for  disease,  remove  the  diseased  portion; 
and  in  both  conditions  trim  the  extremities  of  the  bones  so  as  to  afford  sym- 
metrical support  to  opposite  bony  surfaces.  The  wounds  are  closed  in  the 
usual  manner,  drained,  and  dressed  antiseptically.    It  is  necessary  to  remem- 


FiG.  408.— a.  Lan- 
genbeck's  inci- 
sion, b.  Ollier's 
incision. 


Fig.  409.— Listen's 
incision. 


398 


OPERATIVE  SURGERY. 


ber  in  all  cases  of  excision  of  the  elbow  joint  to  respect  the  insertions  of 
important  muscles,  such  as  those  of  the  brachialis  anticus,  biceps,  triceps, 
etc.  To  unnecessarily  destroy  the  power  of  one  of  these  is  to  be  guilty  of 
an  unpardonable  neglect.  Variously  formed  incisions  other  than  those 
described  have  been  employed,  as  the  H  (Moreau),  with  the  horizontal  por- 


FiG.  410. — Exposing  internal  condyle. 

tion  corresponding  to  the  articulation  ;  U-shaped  or  semilunar,  with  the  con- 
vexity downward.     Either  of  these  imperil  the  insertion  of  the  triceps. 

The  After-treatment. — Anchylosis  and  flail  joint  are  not  infrequent  se- 
quels of  excision  of  the  elbow  joint.  The  former  depends  very  often,  indeed, 
on  a  too  limited  and  the  latter  on  a  too  free  removal  of  bone.  At  the  outset 
the  divided  extremities  should  be,  when  undisturbed,  not  less  than  half  to 
three  quarters  of  an  inch  apart,  with  the  forearm  midway  between  supina- 
tion and  pronation,  and  be  thus  maintained  during  the  major  portion  of  the 
healing  by  a  properly  constructed  splint  to  avoid  anchylosis.  The  splint 
should  be  light,  easily  cleansed,  and  have  a  movable  joint  corresponding  to  the 
elbow.  A  bracketed  plaster-of-Paris  splint  with  proper  suspension  is  serv- 
iceable during  confinement  in  bed  (Fig.  411).  At  first  the  forearm  is  placed 
at  a  right  angle  or,  better  still,  at  one  of  one  hundred  and  thirty-five  degrees 


OPERATIONS  ON  BONES. 


399 


as  suits  the  case,  which  angle  is  frequently  varied  rliiririg  the  healing  process. 
Passive  motion  of  all  the  joints  of  the  extremity  should  be  employed  early 
and  continued  during  recovery,  along  with  massage  and  the  use  of  electricity. 
Supination  and  pronation  of  the  forearm  and  passive  motion  at  the  seat  of 
the  false  joint  is  begun  al)out  the  tenth  or  twelfth  day,  according  to  the 
demands  of  the  case.  It  should  not  be  forgotten  that  the  aim  is  to  secure  a 
false  joint,  and  that  every  consistent  effort  to  that  end  must  be  exercised  for 
the  first  two  months  after  the  operation,  even  though  much  pain  be  inflicted. 
The  grasping  and  carrying  of  a  weighted  pail  in  the  hand  is  an  important 
measure  of  treatment  to  overcome  obstinate  flexion  of  the  forearm. 

The  Results. — Excision  of  the  elbow  joint  has  been  performed  with  such 
good  success  that  its  high  rank  is  thoroughly  established.  Although  when 
due  to  injury  the  rate  of  mortality  is  about  twenty  per  cent,  when  due  to 
disease  it  is  less  than  eleven  per  cent.  Of  92  cases  under  asepsis  for  all 
causes,  four  per  cent  died. 

The  Operation  of  Excision  of  the  Ulna. — In  excision  of  the  ulna  an  in- 
cision is  made  along  the  posterior  border  of  sufficient  length  to  expose  the 
diseased  bone,  the  periosteum  is  pushed  aside,  and  section  is  made  at  the 
requisite  point  and  the  diseased  bone  is  removed.  The  dorsal  branch  of  the 
ulnar  nerve  at  the  lower  third  of  the  bone  is  carefully  avoided. 

If  it  be  a  partial  excision  of  the  upper  extremity,  expose  that  portion  by 
an  incision  in  the  same  line  as  for  removal  of  the  entire  bone  ;  elevate  the 
periosteum,  leaving  if  possible  the  attachments  of  the  brachialis  anticus  and 
triceps  muscles  and  avoiding  the  ulnar  nerve  at  the  inner  condyle. 

The  Operation  of  Excision  of  the  Radius. — Make  an  incision  extending 
from  the  styloid  process  of  the  radius,  along  the  outer  border  of  the  anterior 
surface  of  the  forearm  to  the  radio-humeral  articulation,  through  the  integu- 


Fig.  411. — Bracketed  plaster-of-Paris  splint  lor  elbow. 

ment  and  fascia.  Seek  the  outer  border  of  the  supinator  longus,  pass  up- 
ward, separating  it  from  the  flexor  longus  pollicis,  and  going  down  to  the 
bone ;  divide  the  supinator  brevis,  also  the  periosteum  in  the  long  axis  of 
the  radius  ;  elevate  the  periosteum  ;  divide  the  bone  in  the  center  and  re- 
move each  half  separately.     The  insertion  of  the  biceps  and  pronator  radii 


400 


OPERATIVE  SURGERY. 


teres  should  be  carefully  preserved.  If  an  extremity  of  the  bone  is  to  be 
excised,  expose  the  portion  to  be  removed  by  an  incision  made  in  the  same 
line  as  the  preceding ;  raise  the  periosteum  with  equal  caution  and  remove 
the  diseased  portion. 

The  results  of  excision  of  these  bones  are  good,  provided  the  excision  be 
subperiosteal  and  the  epiphyses  be  not  disturbed. 

The  Operation  of  Excision  of  the  Lower  Extremities  of  the  Bones  of  the 
Forearm  (Bourgary). — Make  a  longitudinal  incision  from  just  below  the  apex 
of  the  styloid  process  two  inches  in  length  along  the  dorsal  surface  of  the 
ulna  (Fig.  413,  lateral  incisions).  Divide  the  periosteum  at  the  interspace  be- 
tween the  extensor  and  flexor  carpi  ulnaris  mus- 
cles and  reflect  it  from  the  dorsum  of  the  bone 
inward  to  the  interosseous  membrane.  A  second 
longitudinal  incision  is  made  from  just  below  the 
apex  of  the  styloid  process  two  or  three  inches 
upward  along  the  outer  side  of  the  radius.  The 
periosteum  is  divided  through  the  same  incision, 
the  attachment  of  the  supinator  longus  separated, 
and  the  periosteum  raised  on  the  dorsal  surface 
together  with  the  sheaths  of  the  extensor  tendons. 
The  periosteum  is  then  elevated  from  the  like 
portions  of  the  palmar  surface  of  the  lower  ends 
of  both  bones  around  to  the  interosseous  mem- 
brane. Protect  the  soft  parts  carefully  while  the 
bones  are  being  sawed  through.  The  operation 
can  be  extended  to  the  bones  of  the  carpus  if 
necessary  by  continuing  the  lateral  incisions  down- 
ward. 

Excision  of  the  Wrist  Joint. — Excision  of  this 
joint  is  associated  with  difficult  and  tedious  de- 
tails. The  wrist  joint  consists  properly  of  the 
radius,  articulated  with  the  outer  two  of  the  first 
row  of  carpal  bones.  In  cases  where  excision  is 
necessary  it  is  not  usual  to  find  the  disease  or 
injury  limited  entirely  to  these  structures.  It  is 
important,  however,  to  remove  all  bony  structures 
involved  even  though  they  include  the  two  rows  of  carpal  and  the  contigu- 
ous extremities  of  the  metacarpal  bones. 

The  Important  Considerations. — The  intimate  relation  existing  between 
the  carpal  bones  and  the  continuity  of  their  synovial  surroundings  renders 
them  especially  liable  to  progressive  disease  as  well  as  to  acute  inflam- 
matory processes  (Fig.  413).  Therefore  their  relations  to  each  other 
must  be  carefully  scrutinized,  to  avoid  needless  involvement  of  contiguous 
synovial  sacs,  and  to  impress  the  necessity  of  their  removal  when  dis- 
eased. A  knowledge  of  the  periods  of  development  of  the  epiphyseal 
structures  and  the  bones  of  the  carpus  is  of  pronounced  significance  in 
the   conservative  sense,     The  apices   of   the   styloid  processes   are  about 


Fig.  413. — Lateral  incisions. 


OPERATIONS  ON  BONES. 


401 


Imlf  an  inch  Mow  the  radio-carpal  line.  The  bones  are  firmly  bound 
together  by  strong  ligaments  admitting  of  but  limited  movement  be- 
tween their  surfaces  (Figs. 
414,  415).  They  are  in  close 
relation  to  the  tendons  of  im- 
portant muscles,  which  should 
be  scrupulously  preserved  to- 
gether with  their  sheaths  (Fig. 
416). 

All  diseased  or  detached 
bone  should  be  removed.  If 
a  portion  of  a  carpal  bone  be 
diseased  it  is  better  that  the 
entire  bone  be  removed.  The 
insertions  of  the  muscles  acting 
on  the  carpus  should  be  pre- 
served if  possible.  It  there- 
fore becomes  necessary  for  the 
surgeon  to  carefully  observe 
the  relations  of  important  ten- 
dons, vessels,  and  nerves  to 
the  structures  to  be  removed 

in  order  to  secure  the  best  re-        -^      .-n     o        •  i         i,  ^J.^. 

,,       rm      ,  ■         1  Fig.  413. — Synovial  membranes  of  the  carpus. 

suits.  The  trapezium,  because 

of  its  relation  to  the  thumb  and  the  bases  of  the  metacarpal  bones  of  the  index, 

middle,  and  little  fingers,  on  account  of  the  important  muscles  inserted  there- 


FiG.  414. — Ligaments  of  dorsal  surface  of 
carpus. 


Fig.  415. — Ligaments  of  palmar  surface 
of  carpus. 


into,  are  important.    To  avoid  haemorrhage,  the  relations  of  the  deep  palmar 
arch,  anterior  and  posterior  carpal  branches,  and  dorsal  interosseous  branch 


402 


OPERATIVE   SURGERY. 


to  the  osseous  structures  must  be  noted,  as  well  as  those  of  the  radial  artery 
to  the  dorsum  of  the  wrist,  to  the  styloid  process  of  the  radius  and  the  carpal 

articulation  of  the  thumb.     Subse- 
P\      P         P'  /^  quent  adduction  of  the  hand  is  op- 

posed by  leaving  the  styloid  process 
of  the  ulna  behind. 

Tendons  are  not  divided  except 
they   form   an   insurmountable  ob- 
stacle to  making  the  incision  neces- 
sary for  removal  of  the  bones ;  if  cut 
they  should  be  promptly  sutured.   If 
the  tendons  be  divided  at  a  distance 
from   the    immediate    seat  of    the 
Fig.  416.— Section   through   the   wrist,     a.  operation  and  sutured,  the  chances 
Scaphoid.     6.  Os  magnum,     c.  Semilunar.      .  ,.-    „„,•„„  „4ii  i,„  I'nPrpflqpfl 
d.  Semilunar,    e.  Unciform.    /.  Cuneiform.    ^^  ^^^^^  union  will  DC  mcreasea. 
g.  Pisiform.     A.  Compartment  for  flexor  The  fact  that  subperiosteal  tech- 

tendons.  ^•.  Flexor  carpi  radial^,  y.  Ex-  nique  should  be  followed  when  prac- 
tensor  ossis  metacarpi  pollicis  and  extensor        ^  ^ 

primi  internodii  pollicis.  h.  Extensor  ticable  in  either  partial  or  complete 
carpi  radialis  longior  and  brevior  I.  Ex-  excision  of  the  wrist,  seems  to  be 
tensor    longus    pollicis.      to.    Extensores  4-  i,r  i,  /i 

communis  and  indicis.    n.  Extensor  mini-    well  established. 

mi  digiti.     o.  Extensor  carpi  ulnaris.    i?.  The  Operation  of  Complete  Ex- 

Palmaris  longus.     a'.  Ulnar  vessels.      V.       .    .  „  j,  \ 

Radial  vessels,    c'.  Ulnar  nerve.  <^*«*ow  of  the  Wrist  Joint— Subperi- 

osteal (Langenbeck).  —  Place  the 
forearm  and  hand  of  the  patient  with  the  palm  downward  on  a  table  of 
convenient  height  for  the  operator  and  his  assistants.  Make  an  incision 
through  the  integument,  beginning  at  the  middle  of  the  metacarpal  bone 
of  the  index  finger  at  its  ulnar  border,  and  extend  it  longitudinally  to 
three  fourths  of  an  inch  above  the  lower  extremity  of  the  radius  at  its 
middle  (Fig.  417).  The  deeper  course  of  the  incision  passes  to  the  radial 
side  of  the  extensor  indicis  without  opening  its  sheath,  upward,  over  the 
tendon  of  the  extensor  carpi  radialis  brevior  to  the  radial  side  of  its  inser- 
tion ;  push  the  tendons  going  to  the  index  finger  to  the  ulnar  side  and 
extend  the  incision  upward  to  the  tendons  of  the  extensor  longus  pollicis  and 
the  extensor  indicis,  dividing  the  lower  portion  of  the  posterior  annular  lig- 
ament. Draw  the  tissues  apart  with  suitable  retractors  and  separate  from 
the  bone  with  a  periosteal  elevator  the  fibrous  sheaths  of  the  extensors  of  the 
carpus  on  the  posterior  surface  of  the  radius  ;  the  insertion  of  the  supinator 
longus  muscle  and  the  annular  and  capsular  ligaments  are  then  disconnected 
and  drawn  to  the  radial  side  together  with  the  periosteum ;  the  tendons,  lig- 
aments, and  periosteum  on  the  posterior  surface  of  the  ulna  are  separated  in 
the  same  manner  and  drawn  to  the  ulnar  side.  Open  well  the  radio-carpal 
joint,  flex  the  carpus  and  expose  the  articular  surfaces,  and  separate  the  bones 
of  the  first  row  from  their  connection  with  each  other,  leaving  the  periosteum 
if  possible.  Liberate  the  scaphoid  from  the  trapezium  and  trapezoid,  the 
semilunar  from  the  os  magnum,  and  the  cuneiform  from  the  unciform.  Lift 
them  out,  together  with  the  trapezium  and  pisiform  bones.  The  inner 
bones  of  the  second  row  are  taken  out  if  necessary  after  severing  their  con- 


OPERATIONS  ON  BONES. 


403 


^Ul 


nections  within  the  trapezium  and  the  bases  of  the  metacarpal  bones.  The 
extremities  of  the  radius  and  ulna  can  now  be  forced  through  the  wound, 
carefully  exposed,  and  sawed  off,  avoiding  the  radial  and  ulnar  vessels.  The 
resulting  wound  is  treated  by  antiseptic  measures. 

The  tendon  of  the  extensor  carpi  radialis  brevior  lying  in  the  course  of 
the  incision  may  require  division  to  facilitate  the  proper  separation  of  the 
deeper  parts.  Its  insertion  into  the  base  of  the  second  metacarpal  bone 
may,  however,  be  chiseled  off  instead,  and  repair  by  tenorrhaphy  in  the  one 
instance  and  by  nailing  the  bony  insertion  at  the  proper  site  in  the  other 
should  be  promptly  practiced.  When  necessary  for  convenience  of  removal, 
the  excision  should  be  extended  upward  to  the  distance  of  an  inch  or  an  inch 
and  a  half  above  the  line  of  the  articulation.  Boekel's  operation  consists 
substantially  in  the  extension  of  Langenbeck's. 

The  Operation  of  Complete  Ex- 
cision of  the  Wrist  Joint;  Subperiosteal 
(Oilier). — Place  the  patient  as  in  the 
preceding  instance,  and,  beginning  op- 
posite the  center  of  the  second  meta- 
carpal bone  (Fig.  417,  3),  make  a  radial 
incision  along  the  radial  side  of  the 
extensor  indicis  upward  to  a  point  an 
inch  and  a  half  above  the  line  of  articu- 
lation of  the  wrist  Joint ;  expose  the 
tendon  of  the  extensor  indicis  without 
opening  the  sheath,  draw  it  gently  out- 
ward by  the  aid  of  a  hook,  and  locate 
the  insertion  of  the  extensor  carpi 
radialis  brevior ;  expose  the  base  of  the 
third  metacarpal  bone  at  the  radial 
side  of  the  last-named  tendon;  divide 
the  posterior  annular  ligament  and 
open  the  capsule  of  the  joint  between 
the  tendons  of  the  extensor  indicis 
and  extensor  longus  pollicis ;  draw 
the  former  tendon  outward  along  with 
those  of  the  extensor  longus  digi- 
torum  ;  make  an  ulnar  incision  down 
to  the  bones  at  the  inner  side  of  the 
tendon  of  the  extensor  carpi  ulnaris, 
from  a  point  an  inch  and  a  quarter 
above  the  tip  of  the  styloid  process  to 
the  same  distance  below  the  base  of 
the  fifth  metacarpal  bone,  avoiding 
the  nerves  going  to  the  little  finger; 
through  the  incision  already  made  di- 
vest the  carpal  bones  of  their  ligamentous  and  periosteal  coverings  by  small 
rugines  preferably  introduced  first  at  the  radial  side ;  free  the  bones,  expose 


Fig.  417. — Excision  of  wrist  joint.  1. 
Langenbeck's  incision.  3,  3.  Ollier's 
incisions.  1,  4.  Boeckel's  incisions,  a. 
Annular  ligament,  h.  Extensor  carpi 
radialis  brevior.  c.  Extensor  carpi 
radialis  longior.  d.  Extensor  longus 
pollicis.  e.  Extensor  communis  digi- 
torum.  /.  Extensor  indicis.  g.  Ex- 
tensor carpi  ulnaris. 


404 


OPERATIVE  SURGERY. 


and  remove  them  through  the  corresponding  incisions,  saving  if  possible 
the  pisiform,  the  unciform  process,  and  the  trapezium ;  bare  the  radius  and 
ulna  of  periosteum  as  high  up  as  needful,  protrude  the  ends  through  the 
opening  and  divide  them  with  a  saw. 

The  Comments. — In  recent  injuries  it  is  difficult  indeed  to  separate  the 
tissues  from  the  bones,  especially  in  adult  subjects.  In  young  subjects  and 
in  those  in  whom  the  parts  are  affected  with  chronic  inflammation,  the  sepa- 
ration is  easier.  The  tendons  and  their  insertions  are  preserved  much  better 
in  the  subperiosteal  than  in  the  open  method. 

The  Operation  of  Complete  Excision  of  the  Wrist  Joint ;  Subperiosteal 
(Lister). — Begin  the  first  or  radial  incision  at  the  middle  of  the  dorsal 

aspect  of  the  radius  on  a  level 
with  the  styloid  process,  and 
carry  it  toward  the  inner  side 
of  the  metacarpal  articulation 
of  the  thumb  parallel  with  the 
tendon  of  the  extensor  longus 
pollicis  to  the  radial  border  of 
the  second  metacarpal  bone, 
thence  along  that  bone  half  its 
length  (Fig.  418) ;  cut  the  ten- 
don of  the  extensor  carpi  radi- 
alis  brevior,  detach  with  a  knife 
the  tendon  of  the  extensor  carpi 
radialis  longior ;  push  outward 
these  tendons  along  with  that 
of  the  extensor  longus  pollicis 
and  the  radial  artery ;  separate 
the  trapezium  from  the  carpus 
in  the  line  of  the  incision  with 
cutting  forceps,  carefully  avoid- 
ing the  radial  artery ;  bend  the 
hand  backward  to  relax  the 
extensor  muscles  and  dissect  up 
the  soft  parts  at  the  ulnar  side. 
Begin  the  second  or  ulnar 
incision  at  the  anterior  aspect 
of  the  ulna,  at  a  point  two 
inches  above  its  lower  end,  and 
bring  it  downward  in  a  straight 
line  between  the  bone  and  the 
flexor  carpi  ulnaris  to  the  mid- 
dle of  the  palmar  aspect  of  the  fifth  metacarpal  bone  ;  raise  the  posterior  lip 
of  the  incision  ;  expose  at  the  insertion  and  divide  there  the  tendon  of  the  ex- 
tensor carpi  ulnaris,  dissect  it  from  its  groove  without  separation  from  the 
tissues  overlying  it ;  separate  the  extensors  of  the  digits  from  the  carpus, 
divide  the  dorsal  and  internal  lateral  ligaments  of  the  wrist  joint.     Flex  the 


Pig.  418. — Lister's  incisions.  1.  Posterior  radial 
incision.  1'.  Anterior  ulnar  incision.  a.  Ex- 
tensor carpi  radialis  brevior.  b.  Extensor  carpi 
radialis  longior.  c.  Extensor  longus  pollicis. 
d.  Extensor  communis  digitorum.  e.  Extensor 
indicis. 


OPERATIONS  ON  BONES.  405 

carpus,  expose  the  anterior  surface  of  the  ulna,  closely  hugging  the  bone  to 
avoid  injury  to  the  ulnar  vessels  and  nerves,  open  the  articulation  of  the 
pisiform  bone,  and  cut  at  the  base  the  unciform  process  with  pliers.  Divide 
the  anterior  ligament  of  the  wrist  joint ;  sever  the  carpus  from  the  meta- 
carpus with  bone-cutting  forceps ;  extract  the  carpus  through  the  ulnar  in- 
cision, dividing  restraining  ligamentous  connections  therewith  at  the  same 
time ;  cause  the  ends  of  the  radius  and  ulna  to  protrude  through  the  ulnar 
incision  by  forcible  eversion  of  the  hand ;  remove  from  these  bones  all  dis- 
eased tissue,  disturbing  as  little  as  possible  the  extensor  tendons  of  the  thumb ; 
remove  disease  from  metacarpal  extremities,  seize  and  remove  the  trapezium 
without  cutting  the  tendon  of  the  flexor  carpi  ulnaris  as  it  lies  in  the  groove 
in  the  palmar  aspect. 

All  hemorrhage  having  ceased,  suture  the  divided  tendons  and  close  the 
wounds,  allowing  the  more  dependent  incision  to  remain  open  for  drainage. 
Envelop  the  limb  in  antiseptic  dressings,  causing  the  whole  to  be  properly 
supported  by  a  splint  (Fig.  419). 

The  Precautions. — Avoid  the  radial  artery  in  making  the  primary  in- 
cision, and  in  the  removal  of  the  trapezium,  which  bone  is  removed  last  for 
this  purpose.  In  attacking  the  heads  of  the  metacarpal  bones,  recall  their 
relation  with  the  deep  palmar  arch.  The  intimate  association  between  the 
tendons  and  their  contiguous  tissues  must  be  disturbed  as  little  as  possible, 
otherwise  the  vitality  of  the  tendons  will  be  much  impaired  and  perhaps 
destroyed.  The  radius  and  ulna  should  be  maintained  as  nearly  the  same 
length  as  practicable,  to  suitably  support  the  head.  Therefore,  as  little  as 
need  be  of  healthy  bone  should  be  removed  from  either,  the  styloid  process 


Fig.  419. — Esmarcli"s  iuterrupted  splint  for  exsection  of  the  wrist. 


of  both,  that  of  the  ulna  especially,  being  preserved  when  possible.  Any 
sound  portion  of  the  pisiform  should  be  preserved  on  account  of  the  relation 
of  the  bone  to  the  anterior  annular  ligament  and  flexor  carpi  ulnaris.  The 
metacarpal  bone  of  the  thumb  should  be  held  at  the  same  level  as  those  of 
the  remaining  digits,  to  secure  better  symmetry  of  the  hand.  In  excision 
the  adhesions  ought  to  be  broken  before  the  operation  is  begun.  In  instances  of 
local  disease  the  application  of  the  Esmarch  bandages  should  be  applied  with 
caution,  if  at  all.  In  traumatic  cases  the  use  of  this  agent  may  lead  to  a  too 
scant  regard  for  the  safety  of  important  vessels. 

The  After-treatment. — The  indications  for  this  treatment  are  perfect 
cleanliness  and  the  use  of  a  splint  that  will  keep  the  forearm  midway  between 
pronation  and  supination,  thumb  and  fingers  free,  and  the  hand  slightly  ex- 
tended and  abducted.   The  wound  should  be  frequently  observed  and  passive 


406 


OPERATIVE  SURGERY. 


motion  of  the  digits  made  early  and  often.  After  the  wound  is  healed,  pas- 
sive motion  of  the  false  joint  and  the  use  of  massage  and  electricity  should 
be  persistently  employed.    The  simple  wooden  splint  devised  by  Lister  and 


Fig.  420. — Esmarch's  splint  applied. 

the  splint  of  Esmarch  (Figs.  419  and  420)  are  well  adapted  for  the  after- 
treatment.  However,  a  plaster-of-Paris  splint  molded  to  meet  the  indica- 
tions and  protected  with  oiled  silk  and  suspended  or  not  as  required,  can  be 
employed  instead  (Fig.  421), 

Incisions  of  other  shape  are  made  through  which  to  effect  the  removal  of 
the  wrist  Joint ;  but  the  longitudinal  incisions  are  advisable,  since  the  trans- 
verse, or  any  modification  thereof,  may  cause  the  needless  sacrifice  of  impor- 
tant structures. 

The  Results. — Ten  per  cent  die  after  excision  for  disease,  and  fifteen  per 
cent  after  excision  for  gunshot  injuries  without  antiseptic  treatment.     In 


Fig.  421. — Bracketed  suspended  plaster-of-Paris  splint  for  excision  of  the  wrist  joint, 

about  thirty-three  per  cent  of  those  who  recover  the  operation  is  of  little  or 
no  service,  in  about  eleven  per  cent  entirely  satisfactory,  in  the  remainder 
of  an  indifferent  outcome.  Usefulness  is  better  when  done  for  injury  than 
for  disease.    Of  178  cases  under  asepsis  for  various  causes,  3  died. 


OPERATIONS  ON  BONES. 


407 


Excision  of  the  Metacarpo-phalangeal  Joints, — These  joints  can  readily 
be  excised  by  milking  an  incision  about  one  inch  and  a  half  in  length  along 
the  dorsum  of  the  bones  composing  the  joint  at  one  side  of  the  extensor  ten- 
don. The  tissues  in  contact  with  the  bone  are  carefully  raised  and  turned 
aside,  the  joint  exposed,  and  the  requisite  amount  of  bone  removed  by  the 
chain  or  Gigli-Haertel  saw,  or  bone-cutting  forceps. 

The  Comments. — The  excision  of  these  joints  should  not  be  practiced  in 
the  young,  as  the  epiphyseal  tissues  are  thus  destroyed  and  a  digit  of  ques- 
tionable utility  soon  becomes  an  absolute  disfigurement.  Even  in  adults  they 
are  often  a  source  of  greater  inconvenience  than  of  service.  However,  on 
account  of  its  functional  importance,  these  statements  do  not  apply  with 
equal  force  to  the  thumb.  The  operation  is  commended  here,  especially 
when  the  proximal  epiphysis  can  be  preserved. 

Excision  of  tlie  Phalangeal  Joints. — These  articulations  may  be  ap- 
proached either  through  a  longitudinal  incision  made  along  the  side  of  the 
joint  or  by  a  curved  incision  at  the  same  situation  with  the  convexity  down- 
ward. In  either  instance  separate  the  tissues  carefully  down  to  the  extremi- 
ties of  the  bones,  which  when  properly  exposed  can  be  caused  to  protrude 
through  the  incision  by  lateral  flexion  and  the  extremities  can  then  be  re- 
moved. A  terminal  phalanx  is  best  excised  by  means  of  a  U-shaped  palmar 
incision,  leaving  if  possible  the  base  of  the  bone  so  as  to  preserve  the  attach- 
ments of  the  flexor  and  extensor  tendons. 

The  Remarks. — Excision  of  interphalangeal  joints  offers  a  fair  outlook 
for  symmetry  and  usefulness,  especially  if  practiced  after  epiphyseal  union 
has  taken  place.  The  removal  of  an  entire  metacarpal  bone,  even  subperioste- 
ally,  is  not  followed  by  pleasing  success,  except  perhaps  when  associated 
with  already  established  bone  production  dependent  on  periostitis.  The  re- 
moval of  small  portions  of  the  shafts  is  followed  with  satisfactory  outcome 
in  the  majority  of  instances. 

The  after-treatment  consists  in  placing  the  fingers  in  an  immovable  posi- 
tion properly  protected  by  an  antiseptic  dressing,  and  when  repair  begins 
passive  motion  is  made  and  continued  until  the  recovery  is  complete. 

EXCISIONS    OF    THE    LOWEE    EXTREMITIES. 

The  principles  of  action  governing  excisions  of  the  bones  of  the  hand 
apply  with  equal  force  to  excisions  of  the  bones  of  the  foot.  The  im- 
portance of  the  great  toe  especially,  and  of  the  other  osseous  structures  of 
the  anterior  part  of  the  inner  arch  of  the  foot  in  locomotion,  gives  to  them 
and  the  operations  directed  to  their  relief  a  specific  significance.  The 
phalanges  and  metatarsal  bones  of  the  other  toes  are  also  invested  with 
cosmetic  and  mechanical  importance,  and  the  former  importance  exceeds  in 
degree  that  of  the  latter  in  the  order  of  their  location  from  within  outward. 
The  proximal  interphalangeal  joint  of  the  second  toe  and  the  metacarpo- 
phalangeal of  the  third  are  removed  for  the  cure  of  hammer-toe  and  of  meta- 
tarsalgia  respectively. 

The  Phalangeal  Joints  of  the  Tarsus  are  removed  in  a  manner  similar  to 
those  of  the  upper  extremity. 


408 


OPERATIVE  SURGERY. 


A  Metatarso-phalangeal  Joint  is  removed  througli  a  longitudiaal  iaeision 

made  over  the  dorsal  surface  of  the  bones  constituting  the  joint,  at  the  in- 
ner or  outer  aspect  of  the  extensor  tendon,  which  is  pushed  aside  together 
with  the  remaining  surrounding  soft  parts ;  the  ends  of  the  bones  are  then 
exposed,  and  severed  by  the  chain  or  Gigli-Haertel  saw,  or  the  bone  for- 
ceps. The  metatarso-phalangeal  articulation  of  the  great  toe  is  excised  often 
through  a  U-shaped  incision  made  at  the  inner  side  of  the  joint,  with  the 
convexity  downward,  the  center  corresponding  to  the  middle  of  the  joint,  and 
of  sufficient  length  to  freely  expose  the  portions  of  the  bones  to  be  removed 
(Fig.  423,  a,  U-shaped  incision).  Dissect  the  soft  parts  from  the  bones, 
carefully  pushing  aside  the  tendons;  expose  and  remove  the  necessary 
amount  of  the  articulation  with  a  saw  or  forceps.  If  the  operation  be  done 
for  the  correction  of  the  deformity  caused  by  prominence  of  the  head  of  the 
metatarsal  bone  (hallux  valgus),  enough  should  be  removed  to  permit  the 

easy  return  of  the  dis- 
placed toe  to  its  natural 
position,  where  it  is  re- 
tained quietly  till  repair 
is  well  advanced,  when 
passive  motion  is  com- 
menced. 

The  Tarso-metatarsal 
Joints  can  be  excised 
through  a  straight  in- 
cision or  by  raising  a 
semilunar  flap  over  their 
dorsal  surfaces,  avoiding 
division  of  the  extensor 
tendons  which  are  raised 
and  pushed  aside,  while 
the  dorsal  ligaments  connecting  the  bones  are  divided  and  the  joint  cavity 
exposed  by  forced  flexion,  after  which  the  bones  of  the  distal  row  can  be 
divided  with  a  saw  or  bone  forceps.  The  corresponding  extremities  of  the 
tarsal  bones  can  then  be  treated  likewise. 

The  RemarJcs. — This  joint  of  the  great  toe  is  removed  best  in  the  manner 
already  indicated  (Fig.  422,  a).  However,  as  in  the  other  toes,  it  can  be  re- 
moved through  a  straight  incision.  The  metatarsal  bone  of  the  great  toe 
can  be  removed  through  an  incision  extending  its  entire  length,  connected 
at  each  end  with  short  vertical  incisions  (Fig.  422,  &),  or  through  a  flap  of 
similar  length  as  the  preceding  incision,  turned  up  from  below  so  as  to  se- 
cure good  drainage  and  locate  the  scar  in  an  unexposed  position  (Fig.  428,  &). 
Operations  on  the  Tarsal  Joints. — When  separate  tarsal  joints  become  in- 
volved by  disease  or  the  effects  of  traumatic  violence  they  can  be  removed  by 
making  an  incision  over  the  injured  or  diseased  portions,  often  following  the 
line  of  the  seat  of  violence  or  in  the  track  of  sinuses  leading  to  the  disease. 

This  treatment  is,  however,  better  adapted  to  those  joints  having  a  lim- 
ited synovial  membrane  than  to  those  where  the  membrane  extends  between 


Fig.  422.. 


-Lines  of  incision  for  removal  of  head  (a)  and 
entire  bone  (b). 


OPERATIONS  ON  BONES. 


409 


several  contiguous  bone  surfaces.  In  the  latter  case  it  is  often  better  to  re- 
move the  bones  entire  by  aid  of  the  chisel,  saw,  or  gouge.  In  either  instance 
curved  incisions  are  preferable,  provided  they  do  not  divide  important  ten- 
dons and  vessels  (Fig.  423). 


Fig.  423. — Section  of  bones  and  svnovial  membranes  of  the  tarsu? 


Excision  of  the  Calcaneum. — It  is  necessary  that  as  much  as  possible  of 
this  bone  be  saved,  as  it  forms  through  important  ligaments  the  posterior 
pillar  of  the  arch  of  the  foot  and  also  gives  attachment  to  the  tendo  Achil- 
lis  which  exerts  a  powerful  influence  in  locomotion.  A  knowledge  of  the 
periods  of  ossification  of  the  centers  of  this  bone  is  important  indeed  in 
young  subjects,  and  emphasizes  the  wisdom  of  being  conservative  and  care- 
ful. When  gouging  fails  to  remove  the  diseased  bone  excision  becomes  the 
final  resort. 

The  Operation. — A  horseshoe-shaped  incision  is  begun  a  little  in  front  of 
the  calcaneo-cuboid  articulation  and  carried  backward  along  the  side  of  the 
foot  around  the  base  of  the  os  calcis  to  a  corresponding  point  on  the  opposite 
aspect.  This  fiap,  with  the  knife  hugging  the  bone,  is  dissected  up,  expos- 
ing the  entire  under  surface  of  the  os  calcis  (Fig.  424,  excision  of  os  calcis). 
A  second  perpendicular  incision  about  two  inches  in  length  is  then  made 
through  the  middle  of  the  tendo  Achillis  down  to  the  preceding  one.     The 


Fig.  424. — Excision  of  os  calcis. 

resulting  flaps  are  dissected  off  close  to  the  bone,  the  articulation  between 
the  calcaneum  and  the  astragalus  is  opened  posteriorly,  the  ligamentous  con- 
nections are  severed,  together  with  those  between  the  calcaneum  and  the 
28 


410 


OPERATIVE  SURGERY. 


Fig.  425. — a.  Excision  of  ankle  joint  (outer  incision).  6. 
Excision  of  astragalus  (outer  incision),  c.  Excision  of 
OS  calcis. 


other  contiguous  bones,  the  os  calcis  is  taken  away,  and  any  additional  dis- 
eased bone  removed. 

Since  the  preceding  incision  is  greater  than  is  required  to  remove  the 
bone,  Forabeuf  advised  that  the  incision  cease  at  a  point  about  an  inch  and 
a  half  to  the  inner  side  of  the  median  line  of  the  foot  and  be  met  at  the 
outer  side  by  a  vertical  one  two  inches  long  located  in  front  of  and  parallel 
with  the  tendo  Achillis  (Fig.  425,  c).    The  vertical  incision  is  carried  down 

to  the  bone,  and  the  peri- 
osteum along  with  the 
superimposed  soft  parts 
and  tendinous  insertions 
carefully  separated  in  the 
usual  manner.  After  ex- 
posure of  the  under  sur- 
face, the  bone  is  grasped 
at  the  anterior  part  with 
bone  forceps,  depressed, 
denuded  of  ligaments  all 
around,  and  removed 
carefully,  avoiding  injury 
of  the  peronei  tendons. 

The   RemarJcs. — The 
direct  relation  which  this 
bone  bears  to  the  poste- 
rior portion  of  the  arch  of  the  foot,  and  the  attachment  which  it  affords  to 
important  ligaments  concerned  in  the  maintenance  of  the  arch,  invests  the 
bone  with  great  importance  in  walking. 

The  Results. — About  sixty-five  per  cent  of  these  cases  recover  with  use- 
ful limbs ;  about  one  in  twenty  die  from  operation,  with  asepsis  much  less. 
Excision  of  the  Astragalus. — Eemoval  of  the  astragalus  can  be  accom- 
plished through  incisions  of  various  forms,  as  the  oval,  single,  double,  ver- 
tical, etc. 

The  Anatomical  Points. — The  relation  of  the  tuberosity  of  the  scaphoid 
bone  to  the  head  of  the  astragalus  must  be  carefully  observed,  as  it  is  a  cer- 
tain guide  to  the  articulation  just  behind  it,  a  matter  of  obvious  importance. 
The  interosseous  ligament  and  its  characteristics  should  be  carefully  noted 
before  operation. 

The  operation  by  the  oval  incision  is  the  oldest  method,  and  is  objection- 
able because  of  the  great  degree  of  disturbance  it  causes  to  the  tendons  on 
the  dorsum  of  the  foot.  In  this  incision  the  tendons  are  either  drawn  aside  or 
divided.  If  the  latter,  the  ends  are  united  after  completion  of  the  operation. 
The  oval  flap  extends  between  the  malleoli  on  the  dorsum  of  the  foot  with 
the  convexity  downward.  The  tendons  of  the  extensor  muscles  are  carefully 
pushed  aside,  the  ligamentous  connections  of  the  bone  with  the  tibia,  fibula, 
and  OS  calcis  are  severed,  and  finally  those  with  tlie  scaphoid  as  well.  The 
foot  is  then  extended,  the  bone  removed  from  its  site,  and  the  calcaneum 
placed  in  the  resulting  gap  between  the  malleoli. 


OPERATIONS  ON  BONES. 


411 


The  Operation,  by  Ike  Double  Incision  (Oaler  and  Inner). — The  outer 
incision  begins  in  front  of  the  external  malleolus,  on  a  line  with  the  articu- 
lar cartilage  of  the  tibia,  and  extends  downward  and  forward  parallel  with 
the  outer  border  of  the  tendon  of  the  peroneus  tertius  two  and  a  half 
inches.  A  second  is  made  at  a  right  angle  to  the  preceding,  passing  from 
the  center  of  the  same  downward  and  backward,  and  terminating  a  little 
below  the  tip  of  the  malleolus  (Fig.  435,  &).  The  inner  incision  begins  just 
below  the  tip  of  the  inner  malleolus  and  is  carried  in  a  curved  manner  up- 
ward in  front  of  the  anterior  margin  of  the  malleolus  (Fig.  438,  c).  Through 
the  outer  incisions  the  ligamentous  connections  of  the  astragalus  with  the 
fibula,  tibia,  scaphoid,  and  os  calcis  are  carefully  divided,  and  through  the 
inner  one  the  remaining  ligamentous  attachments  of  the  bone  are  severed. 
The  astragalus  is  removed  through  the  anterior  incision  with  lion-jaw  forceps. 
The  flaps  are  united,  the  wound  is  drained,  and  the  foot  confined  at  right 
angles  with  the  leg  by 
a  fenestrated  plaster-of- 
Paris  splint.  The  opera- 
tion by  a  single  incision  at 
either  side  can  not  be  ad- 
vised on  account  of  the 
limited  room  and  the  re- 
sulting increase  in  the  in- 
jury of  the  tissues. 

The  Results.  —  About 
seventy-five  per  cent  of 
these  cases  recover  with 
useful  limbs. 

Excision  of  the  Ankle 
Joint.  —  Excision  of  the 
ankle  joint  is  now  less 
frequently  performed  than 
formerly.  The  uncertain- 
ty of  the  result  of  the  op- 
eration and  of  the  final 
usefulness  of  the  limb,  to- 
gether with  the  established 
utility  of  prothetic  appli- 
ances after  ankle-joint  am- 
putation, have  almost  elim- 
inated the  operation  from 
the  practice  of  many,  espe- 
cially for  the  removal  of  diseased  bone.  In  the  instances  of  complicated 
fracture  and  of  compound  dislocation,  the  outlook  is  more  promising,  partic- 
ularly when  practiced  with  antiseptic  care.  The  ankle  joint  is  a  hinge  joint 
and  has  no  lateral  movement  except  when  the  foot  is  well  extended,  which 
even  then  is  very  limited.  The  relation  of  the  epiphyseal  centers  to  the  long 
bones,  their  periods  of  union,  the  arrangement  of  the  ligaments  of  the  ankle 


Fig.  426. — Outer  side  of  ankle,  a.  Tendo  Achillis.  b. 
Peroneus  longus.  c.  Peroneus  brevis.  d.  Peroneus 
tertius.  e.  External  malleolus.  /.  Extensor  longus 
digitorum.  g.  Crucial  ligament.  h.  Extensor 
longus  pollicis. 


412 


OPERATIVE  SURGERY. 


Pig.  427. — Removinar  lower  end  of  fibula. 


joint  and  its  synovial  membranes,  are  matters  of  special  importance  in  exci- 
sion. The  landmarks  of  the  joint  are  stated  under  the  consideration  of  am- 
putations at  the  ankle  (page  509  etseq.).  The  indications  calling  for  the  oper- 
ation are  numerous  and  should  be 
well  considered  before  it  is  attempt- 
ed. As  in  all  of  these  operations, 
those  incisions  which  best  preserve 
the  tendons,  vessels,  nerves,  and  peri- 
osteum should  be  practiced,  conse- 
quently longitudinal  incisions  are 
the  ones  that  should  be  employed. 

The  Operation  of  Subperiosteal 
Excision  of  the  Anhle  Joint  (Lan- 
genbeck). — Make  an  incision  about 
three  inches  in  length  along  the 
posterior  border  of  the  lower  ex- 
tremity of  the  fibula  down  to  the  bone  (Fig.  425,  a),  carrying  it  forward 
in  a  hooked  shape  around  the  lower  end  and  then  upward  along  the  an- 
terior border  about  an  inch.  The  periosteum  is  reflected  from  the  bone 
together  with  the  tissues  in  contact  with  it,  thereby  exposing  the  lower 
extremity  of  the  fibula  without  opening  the  tendinous  grooves  of  the  peronei 
muscles  (Fig.  426).  The  fibula  is  then  divided  at  the  upper  end  of  the 
incision  with  a  narrow  saw,  the  lower  fragment  is  pulled  outward,  its  liga- 
mentous attachments  are  severed  (Fig.  427),  and  the  bone  is  removed.  A 
semicircular  incision  is  then  made  about  an  inch  and  a  half  in  length  down 
to  the  bone,  around  the  lower  end  of  the  inner  malleolus  (Fig.  428,  a).  A 
third  and  vertical  one  is  next  made  about  two  inches  in  length  down  to 
the  bone  through  the  center  of  the  internal  malleolus,  connecting  below 
with  the  semicircular  one. 
The  triangular  flaps,  in- 
cluding the  periosteum,  are 
turned  aside  with  the  ele- 
vator, using  care  to  raise 
the  sheaths  of  all  associ- 
ated tendons  from  their 
grooves  and  push  them 
aside;  the  tibia  is  then  di- 
vided at  the  upper  end  of 
the  cut  with  a  saw,  the 
fragment  is  pulled  outward 
with  the  forceps,  freed  from 
the  interosseous  membrane, 
and  removed  (Fig.  429).  If 
it  is  necessary  to  remove  a 

part  or  the  whole  of  the  astragalus  it  can  be  done  through  either  incision; 
the  better,  however,  through  the  internal  one  on  account  of  the  greater 
amount  of  room. 


Pig.  428. — a.  Excision  of  ankle  joint  (inner  incision). 
b.  Excision  of  metatarsal  bone  of  great  toe.  c.  Ex- 
cision of  astragalus  (inner  incision). 


OPERATIONS  ON  BONES. 


413 


Vogt  recommends,  when  excision  is  performed  for  chronic  disease  of  the 
ankle  and  the  contiguous  Joints,  with  the  view  of  getting  a  more  extended 
insight  into  the  diseased  portions,  that  an  incision  be  made  anteriorly, 
midway  between  the  tibia  and  fibula,  beginning  about  two  inches  above  the 
articulation  of  the  ankle  and  extending  downward  on  the  dorsal  surface 
of  the  foot  to  the  medio-tarsal  joint.  The  long  extensor  tendons  are  care- 
fully drawn  to  the  inner  side,  the  tendons  of  the  short  extensor  are  divided 
and  drawn  to  the  outer  side,  the  blood  vessels  carefully  tied  between  two 
ligatures  and  divided,  and  the  capsule  of  the  joint  is  opened  by  a  vertical 
incision ;  the  anterior  ligament  is  then  detached  and  the  head  and  neck  of 
the  astragalus  is  exposed.  If  the  superior  astragalo-scaphoid  ligament  be 
divided,  the  anterior  and  inner  surfaces  of  this  bone  will  be  the  better  ex- 
posed. A  transverse  incision  is  now  made  at  right  angles  to  the  primary 
one,  extending  outward  to  the  tip  of  the  external  malleolus,  leaving  the 


Fig.  429. — Inner  side    of  ankle    joint,     a.  Tibialis  anticus  muscle,     l.  Tendo  Achillis. 
c.  Tibialis  posticus  muscle,     d.  Flexor  longus  digitorum.     e.  Flexor  longus  poUicis. 


/.  Posterior  tibial  artery,    g.  Tuberosity  of  scaphoid  bone. 


tendons  intact.  Divide  the  three  fasciculi  of  the  external  lateral  ligament 
close  to  the  malleolus,  and  cut  the  interosseous  and  internal  calcaneo-astraga- 
loid  ligaments ;  force  the  articular  surface  of  the  astragalus  outward  ;  seize 
the  bone  with  lion-jaw  forceps,  separate  its  remaining  connections,  and 
remove  it.  All  diseased  portions  can  now  be  easily  examined  and  removed 
with  a  minimum  degree  of  disturbance  of  the  healthy  tissues. 

The  Operation  of  JVon -subperiosteal  Excision  of  the  Ankle  Joint  (Busch). — 
An  incision  is  made  down  to  the  bone,  from  one  malleolus  to  the  other,  across 
the  sole  of  the  foot.  The  sides  of  the  joint  are  exposed  by  drawing  the  tis- 
sues forward.  The  os  calcis  is  sawed  through  from  below  upward  and  for- 
ward to  the  anterior  margin  of  the  calcaneo-astragaloid  articulation  and 
pulled  backward  after  the  division  of  the  opposing  ligamentous  structures. 
The  entire  astragalus  can  now  be  removed  through  the  opening  and  also 
the  lower  extremities  of  the  tibia  and  fibula. 


414-  OPERATIVE  SURGERY. 

After  the  removal  of  the  dead  bone  and  the  establishment  of  good  drain- 
age the  fragments  of  the  os  calcis  are  placed  in  position  and  held  there  by 
silver  wire.  The  wound  should  be  dressed  antiseptically  and  no  weight 
allowed  upon  the  foot  until  the  tissues  are  firmly  united. 

The  Comments. — This  method  is  a  very  ingenious  one,  as  it  permits  re- 
moval of  the  diseased  joint  without  impairing  the  tendons  or  their  sheaths. 
It  is  open  to  the  objection,  however,  of  weakening  the  arch  of  the  foot  on 
account  of  the  division  of  the  long  calcaneo-cuboid  ligament  and  the  plantar 
fascia.  The  fact  remains  therefore  that  the  method  of  subperiosteal  exci- 
sion is  especially  adapted  to  the  anatomical  construction  of  this  joint  on 
account  of  the  subcutaneous  location  of  the  lower  ends  of  the  tibia  and 
fibula ;  and  the  excellent  results  that  sometimes  follow  are  dependent  also 
on  the  greater  security  of  the  tendons  and  ligaments  in  this  method. 

The  after-treatment  for  excision  of  the  ankle  joint  consists  in  applying 
an  immovable  dressing  around  the  joint  under  antiseptic  precautions.     This 


Fig.  430. — Bracketed  suspended  plaster-of-Paris  splint  for  excision  of  ankle  joint. 

dressing  may  be  of  plaster  of  Paris,  suspended  or  not  as  seems  desirable. 
The  indications  of  cleanliness,  extension,  and  preservation  of  the  foot  in  the 
proper  axis  of  the  limb  and  the  securing  of  sound  ankylosis  should  be  kept 
in  constant  view  by  the  surgeon.  Not  infrequently  after  subperiosteal  opera- 
tions a  satisfactory  degree  of  motion  at  the  ankle  joint  is  secured.  The 
mobility  of  healthy  contiguous  joints  contributes  much  to  this  satisfactory 
outcome.  Later  the  ingenuity  of  the  maker  of  orthopaedic  appliances  may 
add  much  to  the  serviceableness  of  the  limb. 

The  Results. — Excisions  of  the  ankle  joint  done  before  asepsis  resulted 
as  follows:  Of  459  cases  done  for  disease,  15.8  per  cent  died,  and  of  87 
cases  done  for  gunshot  wounds,  the  mortality  was  36.6  per  cent.  Of  114 
cases  done  under  asepsis  for  all  causes,  3.5  per  cent  died. 

The  prognosis  for  life  is  most  favorable  between  one  and  fifteen  years  of 
age;  most  unfavorable  between  thirty  and  forty  years.    A  large  proportion 


OPERATIONS  ON  BONES. 


415 


of  the  recoveries  from  this  operation  results  in  a  more  or  less  serviceable 
limb  ;  about  nine  per  cent  are  useless. 

Osteoplastic  Resection  of  the  Tarsus  (Wladimirow-Mikulicz). — This 
operation  is  sometimes  practiced  instead  of  amputation  for  relief  from  exten- 
sive disease  and  injury  of  the  tarsal  bones  and  for  paralytic  talipes. 

The  Operation. — Beginning  about  half  an  inch  behind  the  tuberosity 
of  the  fifth  metatarsal  bone,  make  a  transverse  incision  down  to  the  bone 
across  the  sole  of  the  foot  to  a  point  immediately  in  front  of  the  tuberosity 
of  the  scaphoid.  Make  an  incision  down  to  the  bone  at  either  side  of 
the  foot  from  each  end  of  the  transverse  one  upward  and  backward  to 
the  posterior  borders  of  the  respective  malleoli.  Unite  the  upper  ends  of 
these  incisions  by  a  posterior  transverse  one  and  divide  the  tendo  Achillis ; 
flex  the  foot  sharply ;  open  the  ankle  joint  from  behind ;  sever  the  lateral 

ligaments ;  enucleate    and    remove   the 
astragalus  and  os  calcis ;  saw  thin  disks 


Fig.  431. — ^Wladimirow-Mikulicz's  osteo- 
plastic resection  of  the  tarsus,  a.  In- 
cision through  the  soft  parts,  b.  Di- 
vision of  the  bone.  c.  Position  of  the 
foot  after  the  operation. 


Fig. 


433. — Result  after  osteoplastic  re- 
section. 


of  bone  from  the  exposed  extremities  of  the  tibia  and  fibula,  and  from  the 
exposed  surfaces  of  the  scaphoid  and  cuboid  bones;  divide  subcutaneously 
the  flexor  tendons  of  the  toes  so  that  the  latter  may  be  extended  to  a  right 
angle  with  the  dorsum  of  the  foot ;  bring  in  contact  and  fasten  together  the 
sawed  bony  surfaces  with  sutures,  and  close  the  wound  of  the  soft  parts  (Fig, 
431,  c).  The  extremity  is  then  dressed  and  confined  by  means  of  a  plaster- 
of-Paris  splint  until  healing  is  completed,  after  which  it  is  fitted  with  a  suit- 
ably constructed  shoe  (Fig.  432). 

The  Comments. — Berger,  in  order  to  preserve  the  integrity  of  the  pos- 
terior tibial  artery  and  nerve,  approached  the  ankle  joint  through  a  T-shaped 
incision  made  at  the  outer  side.  The  present  high  degree  of  usefulness  and 
comfort  secured  by  prosthetic  appliances  lessens  decidedly  the  utility  of  such 
methods  of  practice. 


416 


OPERATIVE  SURGERY. 


The  Results. — In  nineteen  operations,  of  which  thirteen  were  for  tubercu- 
lar caries,  two  died  of  general  tuberculosis  eight  months  afterward ;  twelve 
made  a  good  recovery,  and  walked  with  more  or  less  ease ;  in  five,  failure 
followed,  three  of  which  required  amputation. 

Excision  of  the  Bones  of  the  Leg. — If  it  be  desired  to  remove  by  ex- 
cision or  otherwise  portions  of  either  of  the  bones  of  the  leg,  the  location 
and  extent  of  the  incision  is  governed  by  the  situation  and  extent  of  the 
injury  or  disease  of  the  bone.  The  bone  should,  however,  be  reached  by  the 
shortest  practicable  course,  which  usually  is  hetween  the  individual  mus- 
cles rather  than  through  their  structures.  After  removal  of  the  bone, 
which  should  always  be  subperiosteal,  the  limb  is  confined  so  as  to  per- 
mit the  new  structure  when  completed  to  fulfill  the  functions  of  its 
predecessor.  Therefore  the  patient  must  not  be  permitted  to  bear  weight 
on  the  limb  till  the  new  bone  becomes  firm,  else  distortion  or  fracture  will 
occur. 

The  Precautions. — Careful  avoidance  of  involvement  of  the  knee  joint 
and  of  injury  to  the  anterior  tibial  and  musculo-cutaneous  nerves  and  the 
tendon  of  the  biceps  should  be  observed  in  dealing  with  the  head  of  the  fibula. 


Fig.  433. — Longitudinal  section  of  the  knee  joint,  a.  Upper  extremity  of  synovial  sac. 
I.  Tendon  of  the  quadriceps  extensors,  c.  Patella,  d.  Pre-patellar  bursa,  e.  Inner 
condyle  of  femur.  /.  Ligamentum  mucosum.  g.  Fatty  tissue  between  ligamentum 
patellae  _and_  synovial  sac.  h.  Bursa  beneath  ligamentum  patella,  j.  Fatty  tissue. 
A;.  Opening  in  synovial  membrane  behind  crucial  ligament  leading  into  inner  half  of 
joint.  I.  Synovial  membrane  reflected  from  crucial  ligaments,  m.  End  of  anterior 
crucial  ligament,    n.  Posterior  crucial  ligament,   o.  Ligamentum  posticum  Winslovcii. 

Excision  of  the  Knee  Joint. — The  knee  joint  can  be  excised  with  com- 
parative safety  to  the  patient  and  with  a  fair  prospect  of  recovery  with  a  use- 
ful limb.  As  in  the  preceding,  the  nature  of  the  cause  demanding  the  oper- 
ation exercises  a  marked  influence  on  the  result. 


OPERATIONS  OX  BONES. 


417 


The  Anatomical  Points. — Much  is  said  regarding  these  points  in 
connection  with  amputations.  Still,  it  will  not  be  amiss  to  remind 
the  reader  that  the  popliteal  artery  is  closely  associated  with  the  liga- 
mentum  posticum  Winslowii  which  separates  that  vessel  from  the  joint 
cavity  (Fig.  196,  /).  If  ordinary  care  be  exercised  there  is  but  little  dan- 
ger indeed  of  injury  to  this  vessel  unless  there  be  extensive  disease  and 


Fig.  434. — Mackenzie's  anterior  curved  incision. 

deformity  of  the  ligament,  when  the  vessel  may  be  nicked  in  the  removal  of 
the  diseased  tissue  in  spite  of  great  caution,  as  has  once  happened  in  the 
practice  of  the  author.  When  it  is  necessary  to  remove  diseased  tissue  at 
this  situation  the  presence  of  pulsation  of  the  popliteal  artery  will  be  of  in- 
estimable aid,  and  therefore  the  circulation  of  the  vessel  should  be  unhin- 
dered at  that  time.  The  articular  arteries  should  be  avoided  if  possible, 
for  their  division  causes  free  haemorrhage.  The  superior  ones  pass  above  the 
respective  condyles  of  the  femur ;  the  inferior  internal  pass  below  the 
inner  tuberosity  of  the  tibia  and  beneath  the  internal  lateral  ligament ;  the 
external  just  above  the  head  of  the  fibula  and  beneath  the  external  lateral 
ligament.  The  synovial  membrane  of  this  joint  is  extensive  and  replete  with 
small  pockets,  which  may  interfere  with  proper  drainage  and  the  removal  of 
diseased  processes.  The  bursa  of  the  popliteus  muscle  communicates  with 
the  joint  and  not  infrequently  with  the  superior  tibio-fibular  articulation  at 
the  same  time,  therefore  an  unguarded  interference  with  this  articulation  ex- 
poses the  general  cavity  to  the  danger  of  inflammatory  involvement.  The 
synovial  elongation  upward  beneath  the  tendon  of  the  quadriceps  is  well  ex- 
hibited in  the  illustration  (Fig.  433).  The  relation  of  this  extension  to  a 
similar  and  subsidiary  bursa  above  is  explained  sufficiently  in  connection  with 
amputation  at  the  knee  joint  (page  521).  With  the  leg  extended  this  elonga- 
tion ascends  beneath  the  quadriceps  to  its  highest  point,  but  when  the  leg  is 
completely  flexed  it  reaches  scarcely  above  the  anterior  limit  of  the  articular 
cartilage  of  the  femur.  Therefore  the  leg  should  be  flexed  to  avoid  opening 
the  joint  in  incisions  made  at  the  lower  and  anterior  aspect  of  the  thigh. 
The  lines  of  epiphyseal  junction  of  the  femur  and  tibia  at  the  knee  should  be 
located  carefully  in  the  young  before  excision,  so  that,  if  possible,  they  may 


418 


OPERATIVE  SURGERY. 


be  left  undisturbed  and  contribute  still  further  to  the  growth  of  the  bone. 
In  a  child  of  eight  years  of  age,  no  more  than  two  fifths  of  an  inch  can  be 


Pig.  435. — Sawing  off  lower  end  of  femur. 

removed  from  the  tibia,  nor  more  than  three  fifths  from  the  femur,  without 
invading  the  epiphyseal  cartilage.  At  puberty  three  fifths  of  an  inch  can 
be  removed  from  each.  Very  often,  indeed,  disease  of  the  epiphyseal  struc- 
ture modifies  or  destroys  the  power  of  subsequent  development,  and  inevitable 
deformity  follows.  If  the  leg  be  slightly  flexed,  or  the  joint  cavity  distended, 
the  apex  of  the  patella  corresponds  to  the  articular  line  of  the  joint. 

There  are  two  well-known  methods  of  excision  of  this  joint :  1,  the  non- 
subperiosteal,  or  ordinary ;    and  2,  the  subperiosteal  method.     The  former 

is  employed  only  when  the  tissues  are  too 
extensively  destroyed  or  diseased  to  admit 
of  the  saving  of  the  periosteum. 

The  Operation  of  Non  -  subperiosteal 
Excision  of  the  Knee  Joint  (Mackenzie). — 
Flex  the  leg  to  a  right  angle  and  make  a 
curved  incision  from  the  posterior  border 
and  upper  portion  of  the  inner  condyle 
around  to  a  corresponding  point  on  the 
outer,  with  the  convexity  downward  and 
extending  to  the  insertion  of  the  liga- 
mentum  patellae  (Fig.  434).  This  incision 
divides  the  tissues  down  to  and  opens  the 
anterior  portion  of  the  capsular  ligament. 
The  limb  should  now  be  still  more  strong- 
ly flexed,  the  flap  turned  upward,  and  the 
Fig.  436.— Sawing  off  upper  end  of  lateral  and  crucial  ligaments  divided.     A 

retractor  is  then  passed  between  the  liga- 
mentum  posticum  Winslowii  and  the  posterior  surface  of  the  condyles  of 
the  femur,  the  lower  end  of  the  femur  bone  pushed  forward  and  cut  off  on  a 


OPERATIONS  ON  BONES. 


419 


plane  at  right  angles  witli  the  long  axis  of  the  bone  (Fig.  435)  and  parallel 
with  that  of  the  distal  surface  of  the  condyle,  provided  the  extent  of  the 
disease  will  admit.    The  head  of  the  tibia  is  then  exposed,  pushed  forward. 


437. — Szymanowski's  saw. 

and  sawed  in  the  same  manner  with  similar  care,  being  careful  to  avoid  the 
articulation  of  the  fibula  (Fig.  436).  The  peculiarity  of  the  saw  devised  by 
Szymanowski  (Fig.  437  and  page  364)  makes  it  useful  in  sawing  these  and 
other  bones  of  large  size. 

In  this  operation  it  is  better  to  remove  the  patella,  since  its  means  of 
attachment  (the  ligamentum  patellse)  has 
been  severed.  All  inflamed  or  degener- 
ated synovial  membrane  should  be  dis- 
sected away ;  sinus  tissues,  too,  should  be 
thoroughly  removed. 

The  wound  is  then  wiped  or  flushed 
with  a  hot  aseptic  solution,  and  drainage 
established  from  side  to  side  behind  the 
bones,  the  divided  ends  of  the  bone  are 
wired  or  pegged  together,  the  soft  parts 
sutured,  the  whole  limb  is  enveloped  in 
antiseptic  dressing,  and  immovably  fixed 
in  properly  suspended  bracketed  plaster 
or  a  wire  cradle  splint. 

The  Operation  of  Excision  by  a 
Transverse  Incision  (Bird). — Ascertain 
the  line  of  junction  of  the  articulation 
with  the  limb  extended,  if  the  condition 
of  the  joint  will  permit;  make  a  trans- 
verse incision  from  one  condyle  direct- 
ly across  to  the  other,  passing  over  the 
middle  of  the  patella  or  its  apex  (Fig. 
438) ;  if  the  former,  saw  the  patella 
through  in  the  line  of  the  incision,  re- 
move the  fragments,  after  which  the 
joint  surfaces  are  exposed  and  removed  as  in  the  preceding  operations.  This 
incision  affords  the  opportunity  to  establish  good  drainage,  and  exposes  the 
joint  with  a  minimiim  injury  of  the  soft  parts. 


Fig.  438. — Incision  and  exsection  of  the 
knee. 


420 


OPERATIVE  SURGERY. 


Tlie  Operation  of  Subperiosteal  Excision  of  the  Knee  Jot7ii(Langenbeck). 
— Extend  the  limb  and  make  a  curved  incision  five  or  six  inches  in  length 
on  the  inner  side,  commencing  at  the  inner  border  of  the  rectus  femoris 
and  terminating  below  at  the  crest  of  the  tibia.  The  convexity  of  this 
incision  turned  backward  corresponds  to  the  posterior  borders  of  the  con- 
dyle and  tuberosity,  and  its  center  to  the  line  of  the  articulation  (Fig.  439). 
If  the  flap  be  now  raised,  the  vastus  internus  muscle  and  the  tendons  of  the 
adductor  magnus  and  sartorius  will  be  seen  (Fig.  440),  and  should  be  care- 
fully avoided.  Divide  the  internal  lateral  ligament  on  a  line  with  the  articu- 
lation; with  the  periosteal  elevator  separate  the  capsular  ligament  together 
with  the  internal  semilunar  cartilage  and  the  periosteum  from  the  anterior 
and  posterior  surfaces  of  the  inner  condyle  of  the  femur  and  the  tibia  out- 


FiG.  439. — Langenbeek's  incision. 


Fig.  440, — Tendons  at  inner  side  of  knee 
joint,  a.  Vastus  internus  muscle,  h. 
Rectus  femoris  muscle,  c.  Sartorius 
muscle,  d.  Adductor  magnus  muscle, 
e.  Gracilis  muscle.  /.  Semimem- 
branosus muscle.  g.  Semitendinous 
muscle,     h.  Gastrocnemius  muscle. 


ward  to  the  median  line  of  the  bones;  flex  the  leg,  then  extend  it  slowly, 
and  at  the  same  time  dislocate  the  patella  outward  with  the  thumb  applied 
to  its  inner  border;  divide  the  crucial  ligaments;  also  divide  by  a  semi- 
lunar incision  carried  a  few  lines  below  the  tip  of  the  external  condyle ;  divide 
the  external  lateral  and  the  adjacent  portion  of  the  capsular  ligament;  re- 
move the  periosteum  and  its  associated  tissues  from  the  outer  aspect  of  the 
tibia  and  femur,  the  same  as  at  the  inner  side;  divide  the  posterior  por- 
tion of  the  capsule  and  force  the  extremities  of  the  femur  and  tibia  in  turn 
through  the  wound,  and  saw  them  as  before.  The  patella  remains  unmo- 
lested, except  it  be  diseased,  when  the  diseased  portion  is  removed  with  a 
gouge,  or  the  bone  can  be  enucleated  from  the  periosteal  surroundings  by 
the  elevator  and  scalpel.    A  small  opening  should  now  be  made  at  the  outer 


OPERATIONS  ON   BONES. 


421 


Fig.  441.— Olli- 
er's  incision. 


and  one  at  the  inner  side  of  the  wound  posteriorly,  for  the  purpose  of  estab- 
lishing thorough  drainage.  A  drainage  tube  can  be  passed  through  the  upper 
synovial  pouch,  or  firm  compression  can  be  made  thereon  to  prevent  the  col- 
lection of  inflammatory  products  within  it.  The  surfaces  are  then  cleansed, 
all  hsemorrhage  is  arrested,  the  flaps  are  united,  and  the  limb,  / 

surrounded  by  antiseptic  dressing,  is  immovably  fixed  till 
future  dressings  become  necessary. 

The  Operation  of  Subperiosteal  Excision  of  the  Knee 
Joint  (Oilier). — Make  an  incision  through  the  soft  parts, 
commencing  two  inches  above  and  to  the  outer  side  of  the 
patella,  carry  it  down  to  the  upper  and  outer  angle  of  the 
patella,  along  the  outer  border  toward  the  apex  and  thence 
along  to  the  outer  side  of  the  ligamentum  patellae  as  far  as 
to  its  insertion  (Fig.  441);  denude  the  outer  condyle  of  the 
femur  of  its  periosteum  together  with  the  lateral  and  cap- 
sular ligaments  and  the  outer  head  of  the  gastrocnemius; 
denude  the  anterior  and  internal  surfaces  of  the  femur ;  cut 
the  crucial  ligaments;  displace  the  patella  inward  over  the 
inner  condyle;  flex  and  carry  the  leg  inward,  causing  the 
femur  to  protrude,  when  the  end  is  isolated  and  sawed  off. 
The  upper  end  of  the  tibia  is  then  denuded  of  its  periosteum 
from  above  downward,  pushed  through  the  opening  and  likewise  divided. 
If  the  patella  be  diseased,  remove  it,  leaving  its  periosteum  behind. 

The  Remarks. — In  sawing  through  the  exposed 
extremity  of  either  bone,  the  line  of  incision  may 
be  made  to  include  the  whole  of  the  diseased  os- 
seous tissue.  If,  however,  carious  bone  or  an  ab- 
scess cavity  extend  in  an  isolated  manner  into  the 
sawed  extremity  of  the  femur  or  tibia,  it  can  be 
scooped  out,  and  the  resulting  cavity  drained  by 
making  an  opening  with  a  bone  drill  through  the 
bottom  and  continuing  it  to  the  external  surface, 
thereby  saving  the  surrounding  healthy  bone  tissue 
and  thus  contriljuting  to  the  length  of  the  limb. 
Deeply  congested  cancellous  bone  tissue  should  be 
preserved,  especially  if  its  removal  will  impair  the 
epiphyseal  cartilage  (Fig.  443).  Such  diseased  bone 
makes  a  good  recovery,  and  contributes  to  the 
preservation  of  the  growth  of  the  femur.  The  lines 
of  section  of  the  sawed  surfaces  of  the  bones  must 
be  parallel  with  each  other  with  the  leg  in  the 
straight  position  (Fig.  443,  a  &,  a'  c'),  otherwise  their 
union  will  cause  an  angular  deformity.  This  fact 
applies  more  particularly  to  those  cases  where  anchy- 
losis in  the  straight  position  is  sought.  If  for  any  reason  it  be  thought 
better  to  anchylose  the  limb  with  slight  flexion,  then  the  thicker  portions 
should  be  taken  from  the  posterior  parts  of  the  bones  (Ji  k,  i  ;). 


Fig.  442. — Saw  lines  in  ex- 
cision of  the  knee  joint. 


422  OPERATIVE  SURGERY. 

The  limb  should  be  firmly  fixed,  with  the  bone  surfaces  suitably  in  contact 
with  each  other,  before  the  wounds  of  the  soft  parts  are  closed.  If  any  diseased 
tissue  remains  it  may  produce  a  general  infection  of  the  wound,  and,  even  if  not 
causing  a  fatal  issue,  its  non-removal  would  be  followed  by  delayed  and  unsatis- 


FiG.  443. — Epiphyseal  cartilage  and  line  of  section  in  excision  of  knee  joint. 

factory  recovery.   Therefore,  the  synovial  pouches  and  sawed  surfaces  should 
be  carefully  inspected  for  the  presence  of  objectionable  morbid  products. 

If  the  limb  be  anchylosed  in  a  flexed  position,  it  should  be  corrected  as 
much  as  possible  by  Buck's  extension  before  operation,  to  lessen  the  other- 
wise needless  sacrifice  of  bone,  and  obviate  undue  stretching  of  the  popliteal 
tissues  incident  to  correction  at  the  time  of  operation,  and  the  common 
sequel  in  such  cases — backward  displacement  of  the  head  of  the  tibia.  The 
use  of  the  elastic  bandage  in  excision  of  this  joint  enables  one  to  distinguish 
the  presence  of  disease  of  the  synovial  and  osseous  structures  better  than 
without  it,  and  to  complete  the  dressing  of  the  part  without  the  presence 
of  bleeding,  if  such  a  course  be  advisable.  Certainly  the  latter  procedure 
should  not  be  practiced  unless  competent  surgical  skill  be  at  immediate 
call.  It  is  far  better  and  more  secure  to  arrest  all  bleeding  before  closing 
and  dressing  the  wound.  Since  diseased  synovial  membrane  should  be  care- 
fully dissected  away  before  the  wound  is  closed,  the  anterior  pouch  should 
be  cautiously  explored  for  this  reason.  In  all  forms  of  excision  of  this  joint, 
care  must  be  taken  to  prevent  the  soft  parts  posterior  to  the  bones  from 
being  caught  between  their  sawed  surfaces,  since  this  occurrence  will  hinder 
union  by  preventing  a  proper  contact  of  the  surfaces.  If  the  two  wire 
sutures  be  carried  from  in  front  through  to  the  posterior  borders  of  the 
bones,  and  united  at  the  anterior  surface,  this  accident  can  not  occur, 
neither  will  it  happen  if  the  surfaces  be  placed  in  contact  and  confined 
there  by  muscular  contraction  or  a  closely  fitting  splint.  The  fixation  of 
the  bones  by  metallic  sutures  and  needles,  bone  pegs,  etc.,  is  open  to  the 
objection  that  it  may  be  necessary  later  to  remove  them  for  relief  of  the 
irritation  which  their  presence  provokes.  Pegs  driven  from  without  through 
the  integument  and  bone  in  opposite  directions,  so  as  to  hold  firmly  together 
the  sawed  surfaces,  as  practiced  by  Barker,  Wyeth  and  others,  are  efficient 
in  many  cases.     However,  if  the  apposed  surfaces  can  be  firmly  held  in 


OPERATIONS  ON  BONES. 


423 


jDosition  with  apparatus,  the  use  of  these  devices  can  lie  properly  omitted. 
If  the  patella  be  permitted  to  remain,  its  severed  ligament  may  he  united 
by  suturing,  or,  if  the  bone  have  been  sawed  across,  the 
bony  fragments  may  be  united  by  strong  catgut  or  sil- 
ver wire.  It  is  thought,  in  cases  of  imperfect  union 
of  the  tibia  and  femur,  that  the  presence  of  the  patella 
gives  greater  stability  to  the  limb  (Fig.  444). 

The  idea  of  confining  the  sawed  surfaces  (Konig) 
to  each  other  by  nailing  the  attached  portion  of  the 
bisected  patella  to  properly  sawed  surfaces  of  the 
femur  and  tibia  is  certainly  ingenious,  and  in  favorable 
cases  can  be  employed.  If  successful,  it  will  offer  a 
strong  obstacle  to  backward  displacement  of  the  tibia. 
In  fifteen  cases  of  excision  the  wire  was  employed  by 
the  author,  and  in  five  nothing  but  the  splint  was 
used  for  this  purpose;  the  results,  so  far  as  union 
was  concerned,  were  equally  satisfactory.  The  wire 
caused  trouble  in  only  three  instances ;  in  one,  a  necro- 
sis along  its  course,  in  the  remaining  two  a  local  irrita- 
tion due  to  pressure,  which  was  promptly  relieved  by  removal  of  the  wires. 

After-treatment. — The  wire  cradle  splint  and  the  fenestrated  plaster-of- 
Paris  splint  confining  the  entire  extremity,  and  properly  swung  with  elastic 
bandages,  were  employed  consecutively  or  singly  in  each  of  the  author's 
cases  (Fig.  445).  After  the  soft  parts  are  united  the  application  of  a  plaster- 
of-Paris  spica,  as  in  fracture  of  the  thigh,  and  out-of-door  exercise  on 
crutches  are  very  important  measures  of  treatment.  That  strict  antisepsis 
and  good  drainage  are  essential  needs  no  remark. 


Pig.  444. — The  arrange- 
ment of  nails  in 
resection  of  knee 
joint. 


Fig.  445. — Suspended  bracketed  plaster-of-Paris  splint. 


The  Results. — Of  1,063  cases  of  excision  of  the  knee  joint  for  all 
causes,  performed  during  the  preaseptie  period,  the  mortality  was  23  per  cent: 
of  580  cases  done  for  disease,  and  under  antiseptic  precautions,  8.24  per 
cent  died.  In  the  author's  24  adult  cases  for  disease,  2  died  (8.3  per 
cent),  one  expectedly,  the  remainder  recovered  with  serviceable  limbs. 


424:  OPERATIVE  SURGERY. 

The  age  of  the  patient  is  a  consideration  not  to  be  underestimated; 
the  results  are  best  from  five  to  ten  years  of  age,  whether  the  operation 
is  for  injury  or  disease. 

When  done  for  disease,  fourteen  per  cent  of  the  results  were  perfect, 
forty-two  were  useful,  and  the  remaining  useless;  of  which  latter  eighteen 
per  cent  required  amputation. 

For  injuries,  about  eighteen  per  cent  were  perfect,  about  sixty-five  per 
cent  useful,  and  in  about  twelve  per  cent  amputation  was  performed. 

When  for  gunshot  injuries,  about  sixty  per  cent  were  useful  and  twenty- 
four  per  cent  required  amputation,  the  remaining  not  accounted  for. 

When  done  for  deformity,  nineteen  and  a  half  per  cent  of  the  results 
were  perfect,  and  about  sixty-eight  per  cent  of  the  patients  had  useful  limbs ; 
the  remainder  not  reported. 

It  appears  that  the  degree  of  usefulness  does  not  depend  upon  the 
amount  of  bone  removed. 

The  removal  of  the  patella  seemed  to  increase  the  degree  of  usefulness 
of  the  limb.  In  excision  of  the  knee  joint  for  all  causes,  before  the 
growth  of  the  patient  is  completed,  great  care  should  be  taken  to 
preserve  intact,  if  possible,  the  epiphyseal  cartilages,  especially  that  of 
the  lower  end  of  the  femur  (Fig.  444).  This  precaution  markedly  lessens 
thereafter  the  liability  to  failure  of  development  of  the  length  of  the. 
femur  upon  the  diseased  side,  because  this  epiphyseal  junction  provides 
normally  for  much  more  than  its  proportionate  share  of  the  growth  in 
length  of  the  bone. 

Arthrectomy. — Arthrectomy,  sometimes  called  evasion,  is  a  conservative 
operation  employed  to  remedy  disease  of  a  joint — usually  the  knee — in  lieu 
of  the  more  formidable  procedure  of  excision.  It  is  applicable  especially  to 
eases  in  which  the  disease  of  the  joint  structures  is  not  extensive,  nor  of  a 
tuberculous  or  suppurative  nature,  and  displacement  is  not  yet  present.  The 
conservatism  of  this  method  is  shown  in  the  young,  since  the  epiphyseal 
structure  need  not  be  impaired  by  the  measure.  Such  instruments  as  curved 
scissors,  mouse-tooth  forceps,  surgical  spoons  and  gouges,  are  required  here 
in  addition  to  the  commoner  implements  of  operation. 

The  Operation  of  Arthrectomy. — The  preparation  and  position  of  the 
patient,  the  extent  of  the  incision,  and  the  exposure  of  the  joint  cavity,  are 
similar  to  the  steps  in  excision.  All  diseased  serous,  ligamentous,  cartilagi- 
nous and  bony  tissues  are  removed  with  scissors,  scoop,  and  gouge,  being 
careful  to  preserve  especially  the  crucial  and  posterior  ligaments.  A  careful 
exploration  of  the  synovial  elongations  and  pouches  is  necessary,  in  order  to 
detect  and  remove  the  disease  products.  Isolated  areas  of  diseased  bone  or 
cartilage  should  be  cautiously  removed  by  scraping  and  gouging.  Arrest 
haemorrhage,  flush  the  joint  with  a  solution  of  aseptic  fluid,  drain  the  cavity 
at  dependent  points,  unite  the  flaps  with  silkworm  gut,  surround  the  part 
liberally  with  antiseptic  dressing,  firmly  bind  in  place,  and  confine  the 
joint  immovably  as  in  excision. 

The  Results. — If  successful,  a  firm,  stiff  limb  of  normal  length  is  pro- 
duced.   At  all  events,  the  danger  incurred  is  less  than  in  excision,  which 


OPERATIONS  ON  BONES.  425 

can,  if  advisable,  be  resorted  to  later  on.  Painstaking  efforts  should  be  made 
to  secure  a  stili'  limb. 

Arthrectomy  of  the  Ankle  Joiiit  (Briins). — Make  two  incisions  downward, 
one  at  either  side  of  the  anterior  aspect  of  the  limb,  from  about  an  inch  and 
a  half  above  the  line  of  articulation  to  the  medio-tarsal  joint ;  separate  the 
borders  of  the  incisions  and  remove  the  diseased  tissues  from  the  anterior 
portion  of  the  joint  by  the  same  means  as  at  the  knee.  The  posterior  por- 
tion of  the  joint  is  then  freed  of  diseased  tissue  through  two  vertical  incisions 
made  one  at  either  side  of  the  tendo  Achillis.  The  part  is  then  treated  as 
after  excision  of  the  joint. 

The  Excision  of  the  Patella. — Excision  of  the  patella,  independently  of 
the  tibia  and  femur,  may  be  necessary  on  account  of  necrosis  or  injury.  In 
such  cases  the  deep  incisions  must  exactly  correspond  in  extent  to  the  diseased 
bone,  for  if  they  be  greater,  the  synovial  cavity  may  be  opened.  The  peri- 
osteum should  be  raised,  and  the  dead  bone  carefully  removed,  if  possible  with- 
out entering  the  joint.  When  the  joint  is  not  involved,  recovery  will  be 
speedy  and  satisfactory  if  the  limb  be  confined  in  the  extended  position  till 
sufficient  repair  has  taken  place  to  warrant  flexion  without  fracture  of  the 
new  bone. 

The  Precautions. — With  the  limb  straight,  the  apex  of  the  patella  in  a 
healthy  joint  is  just  helow  the  joint  line,  but  with  the  limb  slightly  flexed, 
or  with  the  joint  distended,  a  puncture  at  the  apex  readily  enters  the 
joint. 

The  results  in  eleven  cases,  of  which  eight  were  complete,  and  three  par- 
tial, excisions,  were  two  deaths  and  nine  recoveries. 

Excision  of  the  Great  Trochanter. — Excision  of  the  great  trochanter  is 
occasionally  required  on  account  of  caries  of  that  structure.  A  longitudinal 
or  posteriorly  curved  incision  is  made  down  upon  the  bone,  and  the  diseased 
portion  removed  with  the  usual  instruments.  The  branches  of  the  circum- 
flex vessels  and  the  capsular  ligaments  are  to  be  avoided.  The  periosteum 
should  be  saved  when  possible. 

Excision  of  the  Hip  Joint. — It  is  well  before  attempting  this  operation 
to  give  a  brief  survey  of  the  important  ligamentous  and  muscular  attach- 
ments that  are  to  be  respected.  The  extent  of  this  book  is  too  limited  to 
describe  them  in  detail,  and  even  to  do  so  would  hardly  be  in  keeping  with 
the  scope  of  the  work,  therefore  a  standard  work  on  anatomy  should  be  con- 
sulted. 

The  Anatomical  Points. — The  ilio-femoral,  capsular,  cotyloid,  and  even 
the  teres  ligaments,  should  be  carefully  considered  in  connection  with  their 
origins  and  insertions,  so  that  their  attachments  to  the  involucrum  and  peri- 
osteum may  be  maintained.  When  practicable  those  muscles  which  are  con- 
nected with  the  trochanters  major  and  minor  should  likewise  be  preserved 
intact,  in  order  that  their  association  with  the  new  bone  growth  may  give 
to  the  new  joint,  so  far  as  possible,  the  normal  functions  of  the  old.  It 
is  important  to  note  the  fact  that  the  upper  border  of  the  trochanter 
major  is  on  a  level  with  the  center  of  the  hip  joint,  also  tliat  the  epi- 
physes of  the  upper  end  of  the  femur  contribute  but  comparatively  little  to 
29 


426 


OPERATIVE  SURGERY. 


the  growth  of  the  bone  in  length,  which  is  the  result  almost  entirely  of  those 
of  the  lower  end. 

The  hip  joint  may  be  excised  by  two  quite  distinct  methods  of  procedure : 
1.  The  radical  method^  when  no  effort  is  made  to  save  the  periosteum,  and 
the  muscular  and  ligamentous  attachments  about  the  Joint  are  freely  divided. 
This  method  is  applicable  to  malignant  disease  of  the  bone,  and  to  injuries 
causing  extensive  comminution  and  laceration.  2.  The  conservative  method, 
in  which  scrupulous  care  is  exercised  in  the  peeling  off  of  the  periosteal 
tissue  and  muscular  attachments  worthy  of  preservation.  Under  all  circum- 
stances the  acetabulum  should  be  closely  scrutinized  for  the  presence  of  dead 

bone,  which  should  be  removed  cau- 
tiously to  avoid  injury  to  the  pelvic 
contents  by  the  manipulation. 

The  Radical  Operation  of  Excision 
of  the  Hip  Joint  (White). — This  opera- 
tion is  performed  by  placing  the  patient 
on  the  healthy  side,  and  making  a  deep 
curved  incision  with  a  strong  knife  (Fig. 
446),  commencing  at  a  point  midway 


Fig.  446. — ^White's  posterior  curved 
incision. 


Fig.  447. — Sciatic    nerve    and  external 
rotator  muscles. 


between  the  anterior  superior  spinous  process  of  the  ilium  and  the  trochanter 
major,  and  passing  backward  around  the  top  of  the  trochanter  major,  down 
its  posterior  border  about  three  or  four  inches ;  then  dividing  the  insertions 
of  the  muscles  connected  to  the  great  trochanter  (Fig.  447),  drawing  them 
aside  with  a  spatula,  and  exposing  the  posterior  surface  of  the  neck  of  the 
femur  and  the  acetabulum.  The  exposure  will  be  still  more  complete  if  the 
femur  be  rotated  strongly  inward.  If  the  cotyloid  and  capsular  ligaments  be 
now  divided,  and  the  thigh  be  flexed,  adducted,  and  rotated  outward,  the  head 
of  the  bone  will  be  raised  from  the  acetabulum  sufficiently  to  admit  of  the 


OPERATIONS   ON   BONES. 


42'i 


division  of  the  liganientiim  teres,  when  the  complete  escape  of  the  head  of 
the  femur  will  take  place.  The  soft  parts  are  then  protected  by  a  spatula, 
and  the  bone,  exposed  to  the  required  extent,  is  sawed  off  (Fig.  448). 

A   Conservative  Method  of  Subperiosteal   Excision   of  the  Hip  Joint 
(Langenbeck).— Place  the  patient  on  the  sound  side  with  the  thigh  flexed  to 


Fig.  448. — Sawing  oflf  head  of  femur. 


an  angle  of  45°,  and  rotated  slightly  inward ;  make  a  straight  incision  five  or 
six  inches  in  length  in  the  long  axis  of  the  great  trochanter  (Fig.  449),  upward 
and  backward  toward  the  posterior  superior  spine  of  the  ilium,  passing 
through  the  fascia  lata,  fibers  of  the  gluteus  maximus,  and  periosteum  of  the 
trochanter ;  separate  the  surfaces  of  the  wound  with  retractors,  and  with  the 
elevator  and  knife  raise  the  periosteum  and  the  attachments  of  the  muscles 
inserted  into  the  trochanter  major  and  the  contiguous  surfaces,  being  careful 
to  preserve  their  connections  with  each  other ;  next  make  a  longitudinal  in- 
cision along  the  neck  of  the  femur,  through  the  capsular  ligament  and  the 
periosteum.  The  periosteum  of  the  neck  is  then  separated  in  connection 
with  the  attachments  of  the  capsular  ligament  and  the  obturator  externus 
in  a  careful  manner.  If  an  incision  be  now  made  through  the  cotyloid  liga- 
ment, and  the  thigh  be  rotated  outward  and  adducted,  the  head  of  the  bone 
will  be  elevated  from  the  floor  of  the  acetabulum  sufficiently  to  admit  of  the 
division  of  the  ligamentum  teres,  if  present,  after  which  the  head  of  the  bone 
can  be  pushed  through  the  opening  and  sawed  off.  All  diseased  products  are 
now  removed  from  the  acetabulum  with  scoops,  gouges,  chisel  and  mallet, 
etc.,  and  from  elsewhere  about  the  joint  with  proper  means.  After  the  con- 
trol of  hemorrhage,  the  joint  is  flushed  freely  with  an  antiseptic  solution 


428 


OPERATIVE  SURGERY. 


and  drained,  and  the  borders  of  the  wound  are  united  with  silkworm-gut 
sutures. 

Farabeuf,  after  making  the  initial  incision,  located  with  the  finger 
between  the  pyriformis  and  the  gluteus  medius  muscles,  drew  the  muscles 
apart  and  divided  the  periosteum  between  their  insertions,  also  the  cap- 
sular ligament,  and  the  periosteum  of  the  neck  of  the  bone,  all  in  the  line 
of  the  primary  incision.  He  then  exposed  the  trochanter  major  and  neck  by 
reflecting  the  periosteal  flaps  and  the  muscular  attachments  on  either  side 
backward  and  forward  respectively ;  divided  the  periosteum  of  the  neck  of 
the  bone  at  the  line  of  the  articular  cartilage ;  and  then  so  manipulated 
the  thigh  as  to  expose  and  clear  successively  the  remaining  aspects  of  the 
neck  and  trochanter,  after  which  the  bone  was  dislocated,  and  the  requisite 

amount  removed  with  the  saw.  In 
other  important  regards  Farabeuf 
adhered  to  the  preceding  method 
of  action. 

A  Conservative  Metliod  of  Ex- 
cision of  the  Hip  Joint  (Barker). 
— With  the  thigh  fully  extended 
make  an  incision  at  the  front,  be- 
ginning an  inch  below  the  anterior 
superior  spinous  process  of  the 
ilium  and  going  downward  and  a 
little  inward  for  three  inches,  so 
as  to  separate  the  tensor  vaginae 
femoris  and  glutei  muscles  at  the 
one  side  from  the  sartorius  and 
rectus  at  the  other,  down  to  the 
neck  of  the  bone.  Divide  the 
neck  with  a  narrow  saw  in  the 
direction  of  the  wound ;  lift  out 
the  head  of  the  bone,  search  for 
additional  disease  and  remove  it  if 
present  with  the  flushing  gouge  de- 
vised by  Barker  himself.  After  any  such  disease  is  removed,  flush  and  dry  the 
cavity,  place  the  sutures  for  closure  of  the  wound,  fill  the  wound  with  iodo- 
form emulsion,  and  then  tie  the  sutures,  at  the  same  time  pressing  out  what 
may  come  of  the  iodoform  emulsion.  Drain,  if  essential,  dust  the  surface 
with  iodoform,  apply  antiseptic  dressings  with  firm  pressure,  and  confine  the 
limb  with  a  spica  bandage  so  as  to  force  the  remainder  of  the  neck  of  the 
bone  into  the  acetabulum,  where  it  is  retained  to  serve  the  important  pur- 
pose of  support.  During  the  entire  removal  of  diseased  products,  the  wound 
is  flushed  with  hot  sterilized  water  (110°)  through  the  agency  of  the  gouge, 
which  serves  the  double  purpose  of  separating  the  diseased  tissue  and  wash- 
ing it  away  simultaneously  (Fig.  370,  d).  Although  the  natural  opportunity 
for  drainage  of  the  wound  is  indeed  inadequate,  yet,  if  drainage  be  urgent, 
it  can  be  easily  provided  by  separation  of  the  deep  dependent  structures. 


Pig.  449.— Excision  of  hip  joint,     a.  Langen- 
beck's  incision.     &.  Sayre's  incision. 


OPERATIONS  ON   BONES.  429 

In  this  operation  the  short  route  and  the  minimum  degree  of  damage  to  the 
soft  parts,  and  of  haemorrhage,  certainly  bespeak  a  favorable  outcome  in 
proper  cases. 

A  Conservative  Method  of  Excision  of  the  Flip  Joint  (Sayre). — The  fol- 
lowing method  of  excision  is  that  of  the  late  Professor  Lewis  A.  Sayre. 
It  is  subperiosteal  in  all  essential  particulars,  and  possesses  an  advantage 
over  the  one  just  described  in  that  the  primary  incision  is  better  suited  for 
drainage.  The  following  is  substantially  the  description  given  by  Professor 
Sayre.  Place  the  patient  on  the  sound  side,  with  the  thigh  flexed,  and  make 
an  incision  with  a  strong  knife  down  to  the  bone,  commencing  at  a  point 
midway  between  the  anterior  superior  spinous  process  of  the  ilium  and  top 
of  the  trochanter  major;  carry  it  in  a  curved  course  upon  the  bone  to  the 
top  of  the  great  trochanter  midway  between  its  posterior  border  and  center ; 
complete  it  by  carrying  the  knife  forward  and  inward,  making  the  length  of 
the  incision  from  four  to  six  or  eight  inches,  depending  upon  the  size  of  the 
thigh  (Fig.  449,  h).  If  it  be  not  certain  that  the  periosteum  of  the  trochanter 
have  been  divided  by  the  first  incision,  the  knife  should  be  carried  along  the 
same  line  a  second,  and  even  a  third  time  if  need  be.  The  soft  parts  are  now 
drawn  asunder,  exposing  the  great  trochanter,  when,  with  a  narrow,  strong 
knife,  a  second  incision  is  made  through  the  periosteum  only,  at  a  right  angle 
with  the  first,  about  an  inch  or  an  inch  and  a  half  below  the  top  of  the  tro- 
chanter. At  the  junction  of  the  periosteal  incisions  introduce  the  blade  of 
the  elevator,  and  carefully  peel  the  periosteum  from  either  side  as  far  as  pos- 
sible, together  with  the  ligamentous  attachments,  until  the  digital  fossa  is 
reached.  The  insertions  of  the  rotators  into  the  trochanter  major  and  digital 
fossa  are  so  firm  that  it  will  be  impossible  to  peel  them  off ;  they  must  there- 
fore be  carefully  separated  by  short,  parallel  cuts,  so  directed  as  to  remove  as 
well  the  periosteum  with  which  they  are  blended.  After  the  separation  of  the 
tendinous  insertions,  continue  the  elevation  of  the  periosteum  upon  either 
side  of  the  neck,  using  great  care  not  to  rupture  it.  Having  separated  the 
periosteum  as  far  as  can  be  done  safely,  adduct  the  thigh  carefully,  raise  the 
head  of  the  bone  from  the  acetabulum,  and  detach  the  remaining  portion. 
Adduct  and  depress  the  femur  slightly,  being  careful  not  to  tear  the  perios- 
teum, and  lift  the  head  of  the  bone  out  far  enough  to  admit  of  a  division 
just  above  the  trochanter  minor.  Care  should  be  taken  not  to  expose  a  greater 
surface  of  bone  than  is  necessary,  since  necrosis  would  follow  and  hinder  re- 
covery. It  is  better  to  remove  the  trochanter  major,  even  though  it  be  not 
diseased,  since  its  presence  will  impede  the  escape  of  discharges,  and  is  not 
essential  to  obtaining  a  useful  limb  in  cases  where  its  periosteal  covering 
and  muscular  attachments  are  preserved.  In  all  cases  after  the  operation, 
the  wound  should  be  well  irrigated  with  a  strong  solution  of  carbolic  acid. 

Tlie  General  Remarks. — The  period  between  five  and  fifteen  years  of 
age  is  regarded  as  tlie  proper  one  for  excision.  Not  a  little  conflict  of  opin- 
ion exists  regarding  the  stage  of  the  disease  hest  suited  for  operation.  At 
the  present  time,  however,  the  consensus  of  opinion  favors  the  later  rather 
than  the  earlier  operative  attacks.     Whether  or  not  the  trochanter  major 


430  OPERATIVE  SURGERY. 

should  be  left  entire  or  removed  wholly  or  in  part  is  not  agreed  upon  by 
experienced  authorities.  When  the  leaving  of  it  intact  would  interfere 
with  drainage,  expose  to  recurrent  disease,  or  become  a  source  of  irritation 
thereafter,  as  is  apt  to  be  the  case,  it  should  be  removed  wholly  or  in  part  at 
the  time  of  operation.  When  the  points  of  insertion  of  muscles  and  liga- 
ments are  cartilaginous,  a  thin  layer  of  the  cartilage  may  be  removed,  leav- 
ing the  attachments  undisturbed.  The  preservation  of  the  integrity  of  the 
periosteum  is  regarded  as  important  in  the  prevention  of  infiltration  into 
the  surrounding  tissues,  to  provide  attachments  for  serviceable  ligaments 
and  muscles,  and  to  furnish  a  basis  for  the  reproduction  of  the  bone,  which 
it  is  hoped  will  take  place,  each  of  which  factors  will  exercise  an  important 
influence  in  the  establishment  of  a  useful  joint.  However,  much  of  the 
aforegoing  will  prove  fanciful  when  addressed  to  excision  in  adults  for 
relief  from  the  effects  of  traumatic  violence,  since  then  the  separation  of 
the  periosteum  will  be  exceedingly  difficult  and  perhaps  hazardously  slow, 
and  too  often  attended  with  a  degree  of  mutilation  that  will  destroy  so 
much  of  the  membrane  as  not  only  to  defeat  the  purposes  for  which  it  is 
saved,  but  also  to  hinder  subsequent  repair.  The  saving  of  the  periosteum 
in  the  instance  of  infective  disease  is  of  questionable  utility,  because  in- 
completeness of  removal  of  the  infective  process  may  be  followed  by  a 
prompt  return  of  the  primary  infliction.  In  all  instances  of  excision  as 
prompt  healing  as  practicable  should  be  sought  for.  Therefore,  after  secur- 
ing suitable  drainage,  quite  firm  pressure  on  the  surface  should  be  made  by 
carefully  applied  sponges  and  soft  antiseptic  dressings,  which  are  fixed 
securely  in  place  with  bandages. 

The  After-treatment. — Extension,  cleanliness,  and  nutritious  food  are 
essential.  Extension  in  bed  should  be  as  limited  as  possible,  on  account  of 
the  evil  influences  of  confinement  in  these  cases.  However,  extension  with 
the  wire  breeches  (Sayre)  or  the  Thomas  splint  will  enable  the  patient  to 
leave  the  bed  at  an  early  period,  affording  also  an  opportunity  for  dressing 
the  wound  and  providing  the  extension  necessary,  to  prevent  the  end  of  the 
bone  from  pressing  upward  against  the  acetabulum. 

Tlie  Results. — When  done  for  gunshot  injuries  before  asepsis,  about 
ninety-two  and  a  half  per  cent  die  from  the  primary,  about  ninety-one  per 
cent  from  the  intermediary,  and  ninety  and  a  half  from  the  secondary  opera- 
tion. When  done  for  disease,  the  mortality  in  1,700  cases  done  before 
asepsis  was  33  per  cent;  of  644  like  cases  done  under  aseptic  precautions, 
the  mortality  was  7.14  per  cent.  The  most  favorable  age  is  between  five 
and  ten  years,  and  the  best  results  are  said  to  occur  when  the  disease  has  ex- 
isted several  months.  The  rate  is  about  three  per  cent  greater  from  com- 
plete than  from  partial  excisions.  The  rate  of  mortality  is  a  little  improved 
by  the  removal  of  the  trochanter  major  and  the  upper  portion  of  the  shaft; 
it  is  diminished,  however,  in  proportion  to  the  amount  of  diseased  bone 
removed  from  the  head  of  the  femur  downward,  and  is  increased  in 
proportion  to  the  extent  of  the  disease  of  the  ilium.  About  ninety- 
four  per  cent  secure  useful  limbs  when  excised  for  disease.  Com- 
plete   excision    is    followed    by    a    more    useful    limb    than    partial  ex- 


OPERATIONS  ON  BONES.  431 

cision.  The  advent  of  strict  asepsis  and  improved  teclmique  with  judi- 
cious selection  of  cases  has  led  to  the  startling  results  of  only  three  (Wright) 
to  five  per  cent  mortality.  The  usefulness  of  the  liml)  will  depend  very 
much  on  the  amount  of  bone  removed — the  less  the  better — other  things 
being  equal.  However,  the  majority  secure  serviceable  limbs  and  walk 
unaided. 

The  Operation  of  Arthrotomy  for  Old  Unreduced  and  Irreducible  Dis- 
locations of  the  Hip. — Inasmuch  as  the  causes  of  irreducibility  are  various, 
and  relate  to  the  interference  of  the  capsule,  of  tendon  or  of  muscle,  and, 
perhaps,  of  a  fragment  of  bone,  also,  in  no  small  degree  to  the  restraining 
influences  of  the  tissue  changes  incident  to  nature's  conservative  efforts,  to 
say  nothing  of  the  obstacles  also  incident  to  the  abnormal  relations  of  the 
hard  and  soft  parts  with  each  other,  it  becomes  difficult,  if  not  impossible, 
to  indicate  a  systematized  mode  of  procedure  that  will  meet  the  technical 
requirements  of  even  a  limited  number  of  these  cases. 

The  primary  incision  should  be  of  ample  size  to  promote  clear  observa- 
tion and  rapid,  intelligent  effort,  therefore,  when  practicable,  make  it  so  as 
to  expose  the  dislocated  end  of  the  bone,  the  cotyloid  cavity  and  the  estab- 
lished restraining  influences — i.  e.,  the  capsule,  the  muscles  inserted  into  the 
trochanter  major,  and  nature's  contributions  to  repair,  now  exercising  obsti- 
nate restraint.  Barker's  anterior  incision  (page  428)  affords  prompt, 
easy,  and  free  exposure  of  the  anterior  aspects  of  the  joint,  and  ma)^  answer 
admirably  in  early  and  simple  cases  and  in  the  old  dislocations  with  limited 
structural  changes  and  comparatively  free  movement,  and  those  with  limited 
dorsal  or  with  anterior  displacement.  In  instances  of  immobility  with  the 
head  of  the  bone  well  back  on  the  dorsum  or  in  the  sciatic  notch,  especially 
when  of  long  standing  and  attended  with  marked  secondary  changes,  the 
extreme  straight  or  curved  incisions  will  likely  afford  a  better  opportunity 
of  observing  the  object.  However,  in  any  instance  the  head  of  the  bone 
must  be  freely  exposed  and  isolated,  the  route  to  the  acetabulum  made 
clear,  and  when,  on  manipulation  to  secure  return,  obstacles  are  met,  they 
should  be  overcome  by  division  of  capsule,  tendon  and  ligament,  by  perios- 
teal separation  of  muscular  insertions,  and  by  the  removal  of  new  prod- 
ucts; patient  and  painstaking  efforts  of  a  thoroughly  aseptic  character  are 
essential  to  primary  success  and  to  security  of  the  patient,  and  to  the  use- 
fulness of  limb. 

Strong,  straight  and  curved  scissors,  scalpels,  periostotomes,  rugines, 
strong  hooks  (Fig.  375),  and  tapes  to  raise  the  bone  in  place  are  re- 
quired; when  restored,  the  sound  tissues  should  be  repaired  by  sewing  fast 
in  place  the  muscular  insertions  and  providing  temporary  drainage.  The 
patient  should  be  confined  in  bed,  and  the  limb  immobilized  until  healing 
is  effected,  when  the  use  of  crutches  with  employment  of  passive  motion 
are  instituted. 

If  the  head  cannot  be  restored,  then  excision  or  osteotom}''  should  be 
done,  and  the  patient  treated  accordingly.  Usually  excision  has  been  prac- 
ticed.   It  may  be  deemed  wiser  to  take  no  active  measure  whatever. 

llie  Results. — This  method  has  been   practiced   30  times,   of  which 


432 


OPERATIVE  SURGERY. 


number  11  were  reduced.  Of  the  19  failures,  in  18  excision  was  performed, 
and  in  one  osteotomy.  Of  the  11  successfully  reduced,  8  were  func- 
tionally good,  1  died  of  sepsis,  1  was  followed  by  necrosis  of  the  head,  and  1 
by  return. 

Excision  of  the  coccyx  is  oftentimes  done,  though  sometimes  ineffectu- 
ally, for  the  relief  of  coccygodynia.  The  operation  exposes  the  patient  to  no 
danger  and  can  but  remove  a  comparatively  useless  appendage. 

The  Operation. — Place  the  patient  on  the  side  and  expose  the  bone  by  a 
straight  incision  in  the  middle  of  its  long  axis;  isolate  the  bone  carefully 
and  remove  it  with  bone  forceps. 

OSTEOTOMY. 

In  the  liberal  acceptation  of  the  term,  osteotomy  may  be  defined  as  a 
section  of  bone. 


i  -'-^ 


('   \  I) 


s^if^vimKAiimm^i^l*!^^^^^^^^^^^ 


■\    >'':"'S^^ 


Fig.  450. — Instruments  employed  in  osteotomy,  a.  Scalpel,  b,  c,  d.  Chisels,  e.  Mallet. 
f,  g,  h.  Osteotomes.  %  k.  Retractors.  I,  m.  Sponges  wet  with  a  solution  of  carbolic 
acid  to  hold  over  incisions. 

In  a  limited  sense,  however,  it  is  applied  to  the  divisions  of  bone  that  are 
made  for  the  relief  of  deformities  dependent  on  anchylosis,  rickets,  badly 


OPERATIONS  ON  BONES. 


433 


united  fractures,  etc.  The  bone  may  be  divided  either  through  a  free  or  an 
ahridged  incision  of  the  soft  parts.  In  the  former,  a  liberal  incision  of  the 
soft  parts  is  made  down  upon  the  bone,  and  it  is  therefore  called  the  open 
method.    If  the  opening  in  the  soft  parts  be  of  only  sufficient  size  to  admit 


Pig.  451. — Langenbeck's  saw. 


the  entrance  of  the  instrument,  thereby  preventing  observation  of  the  act,  it 
is  denominated  the  ahridged  or  siibcuta^ieous  method.  If  the  bone  be  divided 
directly  through,  in  either  an  oblique  or  transverse  direction,  at  one  situa- 
tion only,  the  act  is  denominated  linear  osteotomy,  and  is  usually  of  the 
abridged  or  subcutaneous  variety'.     When,  however,  a  wedge-shaped  piece 


Fig.  452. — Adams's  saw, 


is  removed,  the  procedure  is  called  cuneiform  osteotomy,  and  is  practiced 
through  a  free  incision. 

The  instruments  employed  in  osteotomy  consist  of  especially  designed 
saws,  chisels,  osteotomes,  mallets,  blunt  hooks,  and  sand  pillows  (Fig.  450). 

Variously  formed  saws  are  employed,  named  usually  for  the  one  who 
designed  them,  as  Langenbeck's  (Fig.  451)  and  Adams's  saws  (Fig.  453). 


Fig.  453. — Shrady's  bone  saw. 

The  blades  are  short  and  strong,  a  quarter  of  an  inch  in  width  and  an  inch 
and  a  half  in  length,  connected  to  the  handle  by  a  strong  shank  three  inches 
long.  The  deviations  from  these  varieties  are  to  meet  special  indications 
rather  than  to  limit  the  use  of  the  instruments. 


434  OPERATIVE  SURGERY. 

The  objections  to  the  use  of  the  saw  not  only  relate  to  the  danger  of 
lacerating  the  contiguous  tissue,  but  more  forcibly  to  the  retention  in  the 
wound  of  the  bone  dust  which;,  failing  to  be  absorbed,  is  apt  to  be  followed 
by  suppuration ;  therefore  the  osteotome  and  chisel  are  better  than  the  saw. 
The  saw  devised  by  Dr.  George  F.  Shrady,  of  this  city,  is  a  good  instrument, 
and  is  described  by  himself  as  follows : 

"  (Fig.  453.)  The  instrument  consists  of  a  staff  with  a  handle  and  blunt 
extremity.  A  portion  of  this  shaft  at  a  short  distance  from  the  extremity  is 
flattened,  one  edge  (B)  being  made  into  a  knife  blade,  and  the  other  (0) 
being  provided  with  saw  teeth.  When  in  position  (3)  either  the  saw  (C)  or 
the  knife  edge  of  the  shaft,  according  to  the  way  the  latter  is  turned,  corre- 
sponds with  the  opening  of  the  cannula.  The  saw  or  knife  can  then  be 
worked  to  and  fro  within  the  cannula  by  a  pistonlike  movement,  the  cannula 
being  steadied  by  grasping  the  flange  or  handle  (D)  (Fig.  454)  at  its  base.  If 
it  be  necessary  to  work  the  instrument  as  an  ordinary  blunt-pointed  sheathed 
saw  or  knife,  the  shaft  can  be  fixed  in  the  cannula  and  made  into  one  piece 
by  a  thumbscrew  in  the  handle.  The  portion  of  the  cannula  at  the  back  of 
the  opening  is  made  extra  strong,  and  is  of  the  same  thickness  as  the  blade, 


Fig.  454. — Shrady's  improved  bone  saw. 

SO  that  in  sawing  there  is  no  stoppage  of  the  passage  of  the  instrument 
through  any  thickness  of  the  bone.  The  soft  parts  are  protected  from  in- 
jury, no  matter  which  way  the  instrument  may  be  worked.  The  saw  blade 
is  blunt  at  its  extremity,  and  is  guarded  on  all  sides  except  in  its  limited 
cutting  surface.  The  same  may  be  said  of  the  knife.  The  working  of  the 
saw  to  and  fro  in  the  cannula  is  sufficient  in  sweep  to  insure  the  division  of 
any  bone  having  a  diameter  less  than  the  cutting  edge.  Still,  as  this  pro- 
cess is  much  slower  than  when  the  saw  is  used  in  the  ordinary  way,  it  is 
perhaps  better  to  restrict  its  employment  to  operations  on  the  smaller  bones, 
to  cramped  localities,  and  to  situations  where  there  is  special  danger  of 
wounding  some  neighboring  vessels.  All  that  is  necessary,  in  using  this  saw 
is  to  thrust  the  trocar  and  cannula  into  the  limb,  the  fenestrum  of  the  cannula 
being  alongside  of  the  bone  upon  which  the  operation  is  to  be  performed. 
The  trocar  is  then  withdrawn,  the  staff  introduced  in  its  place  and  worked 
as  already  described." 

The  chisel  resembles  the  carpenter's  chisel  in  form,  but  differs  from  it  in 
quality  ;  it  has  two  parallel  margins  extending  to  its  cutting  edge,  which  is 


OPERATIONS  ON"  BONES.  435 

beveled  on  one  side.  The  base  of  the  bevel  should  be  an  eighth  of  an  inch 
in  thickness;  if  thicker  than  this  it  may  splinter  the  bone.  The  width 
varies  according  to  the  size  of  the  Ijone  to  be  divided — half  an  inch  being 
suitable  in  the  majority  of  cases.  For  narrow  bones,  a  quarter  of  an  inch  in 
width  is  better  (Fig.  450,  h,  c,  d).  The  width  should  be  less  than  that  of  the 
bone  to  be  operated  upon. 

The  temper  given  to  the  tools  of  the  hardwood  or  ivory  turner  is  best 
suited  for  the  purpose  of  this  instrument,  and  its  efficacy  should  be  tested 
upon  the  thigh  bone  of  an  ox  or  a  like  animal  before  being  used  for  its 
special  purpose. 

The  chisel  should  l3e  sharp,  and  leave  a  smoothly  cut  surface.  This 
instrument  is  employed  only  to  remove  a  wedge-shaped  piece  from  the  bone, 
since  the  shape  of  its  cutting  extremity  will,  like  that  of  the  carpenter's 
chisel,  cause  it  to  go  awry  if  a  straight  section  be  attempted. 

The  Osteotome. — The  osteotome  is  beveled  at  the  end  on  both  sides, 
resembling,  therefore,  a  slender  wedge,  with  the  handle  and  the  blade  con- 
tinuous and  of  the  same  material.  One  border  of  the  blade  should  be 
delicately  marked  in  inches  or  otherwise,  to  determine  the  depth  of  the 
wound.  The  edge  should  be  sharp  enough  to  cut  a  finger  nail,  and  the 
temper  of  a  character  to  withstand  the  strain  required.  The  strength  of 
this  instrument  can  be  tested  the  same  as  in  the  preceding  instance.  Osteo- 
tomes vary  in  thickness  in  order  that  a  section  begun  by  one  of  a  given 
thickness  may  be  continued  on  its  withdrawal  by  the  substitution  of  another 
of  a  lesser  thickness.  The  tops  of  the  osteotome  and  chisel  should  each 
have  a  round  head  against  which  the  thumb  is  pressed  to  steady  the  instru- 
ment (Fig.  450,  /,  g,  h). 

The  mallet  is  made  of  hard  wood,  or  rawhide  constructed  for  the  pur- 
pose; or  an  extemporized  one  may  be  employed  (Fig.  450,  e). 

The  scalpel  is  a  long  one  with  a  sharp-  point  suitable  for  penetrating 
at  once  to  the  bone  (Fig.  450,  a).  Blunt  hooks  are  employed  to  draw  the 
edges  of  the  incision  apart  without  force  (i,  k). 

The  Sand  Pilloiv. — The  dimensions  of  the  sand  pillow  are  usually  about 
twelve  inches  by  eighteen,  made  of  stout  cloth,  and  filled  with  sufficient  fine 
sand  to  permit  the  contents  to  be  moved  from  one  part  of  the  bag  to  another 
without  leaving  any  portion  empty.  It  should  be  dampened  before  use, 
covered  with  a  carbolized  cloth,  and  the  limb  laid  upon  or  rather  imbedded  in 
it.  It  forms  an  efficient  siipport,  and  prevents  the  impulse  of  the  blow  from 
causing  injury  to  the  soft  parts. 

The  Comment^: — The  opening  in  the  soft  parts  leading  down  to  the 
point  of  proposed  section  should  be  limited  in  extent  and  so  located  as  to 
avoid  the  division  of  important  structures  or  injury  to  a  joint.  It  should 
be  made  when  practicable  in  the  long  axis  of  the  fibers  of  the  muscle 
through  which  it  passes  down  to,  but  not  through,  the  periosteum.  The 
blade  of  the  scalpel  should  remain  in  the  incision  till  muscular  contraction 
ceases,  and  then  the  chisel,  osteotome,  or  saw  is  passed  into  the  wound  by  the 
side  of  the  blade  acting  as  a  guide,  after  which  the  knife  is  withdrawn. 

It  is  better  that  the  wound  l)e  larcje  enouafli  to  admit  the  fino-er,  or  even 


436 


OPERATIVE  SURGERY. 


to  permit  inspection  of  the  bone,  than  that  the  tissues  around  a  small  in- 
cision be  treated  with  violence  in  introducing  the  chisel  or  osteotome. 

If  chips  of  bone  are  to  be  removed,  a  larger  incision  is  required  than  if  a 
simple  section  be  intended.  The  patient  should  in  all  instances  be  ansesthe- 
tized,  and  if  advisable  the  limb  rendered  bloodless  by  the  elastic  bandage. 
However,  the  wound  should  not  be  finally  closed  until  the  siirgeon  is  assured 
that  no  significant  degree  of  hsemorrhage  is  liable  to  take  place.  In  all  re- 
spects the  operation  must  be  performed  with  antiseptic  care. 

When  the  blow  is  delivered,  the  osteotome  or  chisel  should  be  firmly 
grasped  and  steadied  by  the  lower  border  of  the  hand  placed  in  contact  with 
the  soft  parts  (Fig.  455).  If  either  instrument  be  held  loosely,  or  be  applied 
to  the  bone  indifferently,  the  blow  of  the  mallet  will  be  both  futile  and  dan- 
gerous. The  edge  of  the  osteotome  should  not  be  so  pointed  or  placed  as  to 
endanger  important  structures  by  a  direct  or  deflected  curve  in  the  course  of 
the  instrument.  The  first  blows  should  be  lighter  than  the  succeeding  ones  so 
that  the  edge  of  the  instrument  may  be 
first  safely  fixed  in  the  bone.  If  the 
osteotome  be  removed,  it  should  be  re- 
placed in  the  original  track  for  obvious 
reasons.  If  the  instrument  be  fixed 
in  the  bone,  it  should  be  loosened  by 
careful  rocking  in  the  direction  of 
the  long  axis  of  the  cutting  edge,  and 
not  the  short,  as  by  the  latter  move- 
ment the  edge  is  liable  to  be  nicked  and 
broken.  The  greater  liability  of  the 
laceration  of  the  soft  parts,  and  of  the 
entrance  of  air  into  the  wound  and  the 
deposit  of  bone  dust  in  it,  are  valid 
objections  to  the  use  of  the  saw  as  com- 
pared with  that  of  the  osteotome. 

Subcutaneous  Division  of  the  Neck  of  the  Femur. — Subcutaneous  divi- 
sion of  the  anatomical  neck  of  the  femur  is  practiced  to  remedy  faulty 
position  of  the  thigh  incident  to  anchylosis  following  hip  disease,  etc. 
The  division  can  be  made  with  the  saw  or  osteotome. 

The  Division  with  the  Saw  (Adams). — Place  the  patient  upon  the  sound 
side,  with  the  bone  to  be  treated  uppermost.  Locate  the  upper  border  of 
the  trochanter  with  the  finger.  Introduce  about  an  inch  above  the  top  of 
the  center  of  the  great  trochanter,  on  the  flat  and  at  a  right  angle  with  the 
neck,  a  long  scalpel  or  tenotome  straight  down  to  the  neck  of  the  femur; 
divide  the  muscles  and  open  the  capsnle  freely  on  the  anterior  and  upper 
surface  so  as  to  .permit  the  easy  entrance  of  the  saw,  which  is  passed  by  the 
side  and  along  the  track  of  the  knife  down  to  the  anterior  surface  of  the 
neck,  which  is  then  sawed  transversely  through  (Fig.  456)  from  before  back- 
ward sufficiently  to  be  easily  broken.  The  limb  is  then  placed  in  the  proper 
position,  the  wound  irrigated  to  render  it  aseptic  and  to  wash  out  the  bone 
dust ;  haemorrhage  is  checked,  a  small  drainage  tube  introduced,  the  remain- 


PiG.  455. — Method  of  holding  osteotome. 


OPERATIONS  ON  BONES.  437 

ing  portion  of  the  incision  closed,  the  whole  area  enveloped  in  antiseptic 
dressings,  and  the  limb  placed  in  an  immovable  apparatus.  The  tendinous 
contractions  that  may  prevent  the  limb  from  .being  properly  corrected  should 
be  divided  subcutaneously. 

The  Remarks. — This  method  of  practice  is  best  suited  to  those  cases  in 
which  the  neck  of  the  femur  has  undergone  no  especial  change.  If  this 
portion  of  the  bone  have  been  shortened,  thickened,  or  eburnated,  or  be  sur- 
rounded with  indurated  tissue,  or  the  head  of  the  bone  be  displaced,  the  use 
of  the  saw  is  contraindicated,  and  the  osteotome  should  be  employed  instead. 
Aside  from  these  facts,  the  deposit  in  the  wound  of  bone  dust  and  the 
probable  bruising  of  the  tissues  with  the  end  of  the  saw  are  regarded  as 
objectionable  features. 

The  Results. — This  operation  has  been  successful  in  thirty-one  out  of 
thirty-four  cases. 

The  Division  ivith  the  Osteotome. — Place  the  patient  on  the  sound  side, 
expose  the  upper  border  of  the  neck  of  the  femur  to  the  osteotome  through 
an  incision  extending  upward  from  the  upper  border 
of  the  great  trochanter  three  quarters  of  an  inch. 
Introduce  the  osteotome  before  removal  of  the  knife ; 
turn  it  so  as  to  divide  the  neck  in  the  direction  of 
the  short  diameter.  A  few  sharp  blows  with  the 
mallet  will  permit  restoration  of  the  limb  with  fracture 
of  the  undivided  portion  of  bone. 

The  Remarhs. — Special  care  must  be  exercised  in 

the  use  of  the  osteotome,  and  in  the  handling  of  the 

limb  during  the  use,  so  as  not  to  cause  fragments  of 

bone  to  be  loosened  or  pushed  into  the  soft  tissues 

by  the  advancing   end  of   the  instrument  or  hy  in- 

.  cautious  movement   of  the   fragments.     The  instru- 

of  femur.  ^  ment  should  be  so  held  and  the  blow  so  directed  as 

to  limit  the  effect  to  the  bone  alone. 

Maunder.,  Billroth,  and  others  have  used  the  chisel  for  forcible  fracture 

with  good  results. 

Division  of  the  NecTc  of  the  Femur  ;  Formation  of  False  Joint  (Volk- 
manu). — While  false  joints  are  often  fickle,  and  in  many  instances  afford 
no  great  advantages  over  those  gained  by  an  increased  compensatory  move- 
ment of  the  spine,  still  by  this  operation  good  results  are  reported  to  have 
been  so  common  as  to  merit  a  more  frequent  trial  of  the  method. 

The  Operation. — Make  an  incision  along  the  posterior  border  of  the  great 
trochanter  four  or  five  lines  in  length  down  to  the  bone.  The  femur  is  then 
cut  through  about  an  inch  below  the  great  trochanter  with  a  chisel,  the  wall 
of  the  cervix  femoris  broken,  and  the  upper  portion  of  the  bone  removed. 
The  thigh  is  then  adducted  to  make  the  upper  end  of  the  distal  frag- 
ment of  the  femur  more  accessible,  then  the  latter  is  cut  across  and  rounded 
off  to  fit  the  new  socket  made  by  chiseling  out  the  head  of  the  femur  and 
increasing  the  area  of  the  acetabulum  by  the  same  process,  being  careful  not 
to  open  into  the  pelvic  cavity.     The  upper  end  of  the  femur  is  placed  in 


438 


OPERATIVE  SURaERY. 


Pig.  457. — Sayre's  lines 
of  section. 


the  newly  formed  cavity,  and  extension  is  applied  to  the  limb  to  keep  the 

cut  surfaces  sufficiently  separated  to  prevent  bony  union.     Early  passive 

motion  should  be  made. 

The  Results. — Volkmann  has  performed  this  operation  several  times, 

obtaining  useful  limbs  in  each  instance. 

The  Division    hy  Inter-trochanteric    Osteotomy    (Sayre's   modification 

of  Barton). — This  operation  consists  in  exposing  the  anterior,  outer,  and 

posterior  surfaces  of  the  femur  through  an  incision 

about  six  inches  in  length,  beginning  just  above  the 

tip  of  the  trochanter  major,  and  carried  longitudi- 
nally through  the  center  of  its  outer  surface.      A 

short,  transverse  incision  is  then  joined  to  the  center 

of  the  posterior  lip  of  the  first;  the  respective  sur- 
faces of  the  bone  are  then  exposed  with  an  elevator, 

until  the  trochanter  minor  can  be  felt,  when  a  chain 

saw  is  passed  around  the  bone  immediately  above  this 

process.     The  first  or  curved  section  (Fig.  457)   is 

made  by  first  sawing  upward  and  outward,  until  the 

bone  is  half  severed,  then  changing  the  direction  to 

downward  and  outward,  and  completing  the  section. 
The  second  or  straight  section  is  made  by  sawing 

directly  through  the  upper  end  of  the  lower  fragment  in  its  transverse  axis  so  as 

to  exsect  a  piece  of  bone  an  eighth  of  an  inch  thick  at  the  outer  and  inner  bor- 
ders, and  three  quarters  of  an  inch  at  its  central  part. 
The  upper  end  of  the  lower  fragment  is  then 
rounded  to  fit  the  concavity  above.  The  limb  is 
straightened  and  the  wound  treated  like  a  compound 
fracture. 

The  Results. — The  removal  of  a  disk  of  bone  in 
this  situation  has  been  quite  frequently  practiced,  but 
with  indifferent  success.  Out  of  the  seventeen  cases 
reported,  seven  died. 

Volkmann  s  Modification. — The  modification  in- 
troduced by  Volkmann  in  1873  consists  in  making  an 
incision  along  the  posterior  border  of  the  great  tro- 
chanter and  upper  portion  of  the  shaft  of  the  femur 
about  three  inches  in  length,  and  removing  the  peri- 
osteum from  two  thirds  of  its  circumference  at  the 
lower  part  of  the  incision,  when  with  chisels  and 
gouges  a  wedge-shaped  piece  is  taken  from  just  below 

the  great  trochanter  (Fig.  458),  and  the  bone  broken,  straightened,  and 

placed  in  proper  position  until  union  takes  place. 

The  Results. — Of  the  twelve  operations  thus  performed,  all  recovered. 
The  Division  of  the  Shaft  deloiv  both  Trochanters  (Gant). — This  method 

of  procedure  is  performed  in  the  following  manner: 

The  Operation. — Make  a  longitudinal  incision  down  to  the  bone  on  the 

outer  aspect  of  the  femur  corresponding  to  the  situation  of  the  lesser 


Fig.  458.— Vol  km  an  n's 
section. 


OPERATIONS   ON  BONES.  439 

trochanter.  Through  this  opening  introduce  the  osteotome  down  to  the 
bone  and  divide  the  bone  transversely  just  below  the  lesser  trochanter  (Fig. 
456,  a). 

The  Remarks. — The  ease  of  approach  to  the  bone,  the  comparative  sim- 
plicity of  the  division,  and  the  uniformly  favorable  outcome  thus  far  secured, 
bespeak  the  adoption  of  this  method  when  practicable,  instead  of  either  of 
the  more  complicated  and  less  favorable  ones  already  stated. 

After-treatment. — In  all  instances  of  division  of  the  neck  of  the  femur 
thorough  drainage  and  aseptic  cleanliness  should  be  practiced.  If  a  false  joint 
be  the  desideratum,  extension  and  passive  motion  should  be  made  to  prevent 
bony  union.  The  latter  is  begun  as  soon  as  the  wound  is  well  healed,  and 
the  former  is  continued  while  the  patient  is  in  bed,  and  even  later  if  need 
be,  by  special  apparatus.  If  bony  union  be  unobjectionable,  the  limb  is 
treated  by  immobilization  apparatus,  the  same  as  for  fracture.  The  choice 
of  operation  will  be  governed  largely,  indeed,  by  the  nature  of  the  desired 
outcome — mobility  or  immobility  at  the  seat  of  division. 

Congenital  Displacement  at  the  Hip  (Hoffa's  operation). — Place  the 
patient  on  the  sound  side  ;  flex  the  thigh  to  an  angle  of  forty-five  degrees, 
make  an  incision  three  or  four  inches  in  length  in  the  long  axis  of  the  great 
trochanter,  upward  and  backward  toward  the  posterior  superior  spinous 
process  of  the  ilium  through  the  tissues,  down  to  the  bone.  Remove  the 
periosteum  and  muscular  attachments  from  the  great  trochanter  with  a  peri- 
osteotome ;  cut  away  the  capsular  ligament  if  it  oppose  reduction ;  enlarge 
the  acetabulum  with  bone  scoops ;  reduce  the  displacement  by  manipulation, 
stretching  or  dividing  muscular  structure  opposing  reduction ;  drain  the 
wound,  dress  antiseptically,  abduct  and  extend  the  thigh,  and  confine  the 
limb  with  a  plaster-of- Paris  spica  until  the  wound  is  healed. 

The  Remarks. — In  children  under  six  years  of  age  the  muscles  can  usu- 
ally be  stretched  sufficiently  to  bring  the  limb  into  proper  position  for 
confinement  during  healing.  In  those  of  six  and  upward  stretching  rarely 
avails,  and  subcutaneous  division  of  the  muscles  attached  to  the  tuber  ischii 
and  of  the  adductor  muscles  is  practiced,  together  with  open  division  of  the 
fascia  lata  and  of  the  soft  parts  attached  to  the  anterior  superior  spine  of 
the  ilium,  as  the  need  for  such  divisions  is  demonstrated  by  putting  the  tissues 
successively  on  the  stretch.  The  ligamentum  teres,  the  cartilages,  the  fatty 
and  a  good  portion  of  the  cancellous  tissue  of  the  acetabulum  should  be  re- 
moved, disturbing  as  little  as  possible  the  margins  of  the  cavity. 

The  After-treatment. — If  the  acetabulum  be  shallow,  the  head  of  the 
bone  should  be  held  in  place  with  extension  or  by  means  of  a  padded  strap 
buckled  around  the  pelvis  and  over  the  trochanters.  If  the  acetabulum  be 
deep  enough  the  head  will  remain  in  position  without  mechanical  aid. 

Hoffa  advises  that  the  limb  be  at  first  moderately  inverted,  abducted  and 
extended,  then  after  a  few  weeks  brought  into  the  normal  position.  The  first 
fixation  dressing  is  retained  in  place  three  or  four  weeks  if  practicable.  For 
weeks  and  perhaps  months  afterward  the  patient  should  not  stand  or  walk 
without  the  support  of  an  apparatus  directed  to  maintaining  the  length  of 
the  limb  while  permitting  motion  at  the  hip  joint. 


440  OPERATIVE  SURGERY. 

The  Results. — Hoffa  reports  112  operations  on  82  patients.  Anchylosis 
of  the  hip  followed  in  9  and  return  of  the  displacement  in  11  cases.  Death 
followed  in  3  cases :  in  2  from  the  effects  of  shock ;  in  1  from  iodoform  poi- 
soning. 

Lorenz's  Modification  of  Hoffa's  Operation. — Place  the  patient  on  the 
back,  with  the  limb  abducted  and  rotated  outward.  Make  an  incision  from 
a  point  two  inches  beneath  the  anterior  superior  spinous  process  of  the 
ilium,  going  obliquely  downward  and  outward  through  the  tensor  vaginge 
femoris  muscle  and  the  anterior  fibers  of  the  gluteus  medius  muscle  and 
the  fascia  lata,  crossing  the  trochanter  at  about  the  middle  of  the  external 
surface  and  extending  to  a  point  just  below  the  long  axis  of  the  femur; 
draw  apart  with  broad,  strong  retractors  the  borders  of  the  tensor  vaginae 
femoris  and  gluteus  medius  muscles,  find  the  rectus  femoris  muscle  and 
locate  its  reflected  tendon  at  the  point  of  insertion  into  the  bone  just  above 
the  acetabulum ;  uncover  the  capsular  ligament  and  incise  it  longitudinally 
so  as  to  expose  the  head  and  neck  of  the  bone ;  cause  the  assistant  to  flex  the 
thigh  to  a  right  angle  with  the  body,  and  free  the  insertions  of  the  capsular 
ligament  from  the  anterior  and  posterior  surfaces  of  the  bone  so  that  the 
finger  can  be  passed  completely  around  its  neck ;  throw  the  head  of  the  bone 
outward;  divide  the  ligamentum  teres  if  present,  and  turn  the  bone  aside, 
thus  exposing  to  view  the  underlying  capsule  and  the  acetabulum;  deepen 
the  acetabulum  with  a  curette,  preserving  as  much  as  practicable  its  bony  rim. 

The  Remarks. — If  the  head  of  the  bone  be  conical,  a  portion  should  be 
removed,  preserving,  however,  as  much  as  is  possible  of  its  articular  carti- 
lage to  obviate  the  anchylosis  that  is  liable  to  follow  the  removal  of  cartilage 
in  deepening  the  acetabulum.  The  finding  of  the  socket  is  sometimes  diffi- 
cult, on  account  of  the  presence  of  fibrous  tissue  and  of  the  overlying  adher- 
ent portion  of  the  capsule.  Portions  of  tissue  that  prevent  reduction  of  the 
head  and  of  its  retention  in  place  with  the  limb  abducted  or  in  a  straight 
position  should  be  severed.  A  short  neck  of  the  bone,  contraction  of  the 
adductor  muscles,  or  a  narrow  acetabulum  may  further  prevent  reduction 
or  proper  retention  in  place.  When  reduction  attends  adduction  of  the 
limb,  forcible  abduction  may  be  employed  to  stretch  the  tissues  hindering 
the  proper  placement  of  the  limb  in  the  normal  position.  Bradford  in  some 
instances  divided  the  Y-ligament  to  effect  a  proper  reduction.  After  sat- 
isfactory reduction  the  divided  tissues  may  be  united  with  buried  catgut 
sutures,  and  the  wound  carefully  drained,  or  it  may  be  packed  with  gauze 
at  the  outset,  as  circumstances  demand.  Prior  to  operation  in  any  method 
the  restraining  tissues  should  be  stretched  for  some  time  with  the  limbs 
in  an  abducted  position  by  weight  and  pulley.  Objectionable  internal 
or  external  rotation  of  the  limb  after  recovery  can  be  remedied  by  division 
of  the  femur  below  the  trochanter,  followed  by  rectification  of  the  deform- 
ity and  the  application  of  the  plaster-of-Paris  spica  until  union  ensues. 
Lorenz  himself  no  longer  practices  this  method. 

The  Results. — Lorenz  reports  excellent  results  in  a  series  of  100  cases. 
Two  cases  were  followed  by  slight  fibrous  anchylosis,  and  one  by  suppuration 
and  complete  anchylosis.  Schauz  reports  135  cases  operated  on  by  twenty-one 


OPERATIONS  ON  BONES.  441 

different  operators.  Death  occurred  from  operation  in  7  and  from  complica- 
tions in  4  cases.  Eight  were  not  satisfactory,  6  perfectly  so,  and  109  were  ex- 
cellent results.  If  a  rudimentary  acetabulum  be  not  present,  Ogston  advised 
that  an  opening  be  chiseled  through  the  ilium  and  the  head  of  the  bone 
adjusted  to  it. 

The  results  in  these  operations  appear  to  be  excellent  when  measured  by 
the  depth  of  the  inherent  difficulties  to  which  they  are  addressed.  The  na- 
ture of  the  infliction  necessarily  renders  infrequent  perfect  cure.  Lorenz's 
method  may  be  regarded  as  the  simplest  and  least  dangerous  of  the  effective 
operative  procedures. 

Bony  Anchylosis  of  the  Knee  Joint.— Bony  anchylosis  of  the  knee  joint 
may  be  associated  with  flexion,  or  with  internal  or  external  deflection  of  the 
leg.  In  either  instance  the  deformity  can  be  practically  overcome,  and  the 
usefulness  of  the  limb  enhanced  by  supracondyloid  osteotomy  of  either  the 
linear  or  cuneiform  variety.  The  anatomical  points  bearing  on  the  operation 
are  in  all  respects  similar  to  those  relating  to  correction  of  genu  valgum. 
And,  too,  the  methods  of  procedure  in  cases  of  deflexion  present  no  substan- 
tial differences  from  those  employed  in  the  operation  for  that  deformity. 

The  Operation  hy  Linear  Osteotomy. — When  performed  from  the  outer 
aspect,  make  a  longitudinal  incision  down  upon  the  bone  at  the  outer  border 
of  the  rectus  tendon,  one  finger's  breadth  above  the  upper  portion  of  the 
outer  condyle,  suflBcient  to  admit  the  osteotome.  The  osteotome  is  intro- 
duced and  turned  so  that  its  cutting  surface  corresponds  to  the  transverse 
axis  of  the  bone  at  the  point  to  be  divided ;  with  the  limb  resting  upon  the 
sand  bag  the  anterior  two  thirds  of  the  femur  is  divided  and  the  posterior 
third  broken  or  bent.  If  performed  from  the  inner  aspect,  the  incision  is  made 
half  an  inch  in  front  of  and  parallel  with  the  anterior  border  of  the  tendon  of 
the  adductor  magnus,  beginning  one  inch  above  its  insertion.  The  remaining 
steps  of  the  operation  are  similar  to  the  preceding.  It  may  be  necessary  to 
supplement  the  section  of  the  femur  with  that  of  the  tibia,  in  order  to  suf- 
ficiently correct  the  deformity.  This  is  done  by  making  an  incision  through 
the  skin  over  the  tibial  crest,  just  below  the  tuberosity.  Through  this  open- 
ing, the  subcutaneous  and  posterior  surfaces  of  the  tibia  are  divided  suf- 
ficiently to  permit  of  a  fracture  of  the  bone  and  the  consequent  correction 
of  the  deformity.  The  fibula,  owing  to  its  mobile  association  with  the  tibia, 
does  not  require  division  at  this  situation.  It  is  often  necessary,  however,  to 
cut  the  hamstring  tendons  before  the  deformity  can  be  properly  corrected. 

The  Operation  hy  Cuneiform  Osteotomy. — Although  this  variety  of  oste- 
otomy may  be  applied  to  deflected  curves,  the  linear  is  much  the  better,  and 
the  cuneiform  method  should  be  rather  employed  in  instances  of  anchylosis 
of  the  knee  with  marked  flexion  of  the  leg.  It  can  be  employed  above 
(Barton)  or  through  the  joint.  The  latter  is  much  the  better  plan.  The 
size  of  the  piece  to  be  removed  can  readily  be  estimated  by  noting  the 
course  of  two  imaginary  lines  dropped  perpendicularly  to  the  long  axes  of 
the  tibia  and  femur  respectively  (Fig.  459).  If  these  lines  be  so  dropped  as 
to  join  at  the  angle  of  the  deformity,  they  will  indicate  the  minimum  amount 
of  bone  that  should  be  removed.  A  still  greater  saving  of  bone  can  be  made 
30 


44:2 


OPERATIVE  SURGERY. 


Fig.  459. — Cuneiform  incision  for  bony  anchylosis  of 
knee  joint. 


if  the  cuneiform  section  ceases  at  the  posterior  third  of  the  transverse 
diameter,  which  part  is  then  overcome  by  fracture  as  the  limb  is  straight- 
ened. In  all  instances  the  lines  of  division  of  the  two  bones  must  be  made 
so  as  to  be  parallel  with  each  other  when  the  leg  is  brought  into  the  cor- 
rect position,  otherwise  a 
new  deformity  will  be  cre- 
ated— deflection  of  the  leg. 
If  the  degree  of  flexion  be  a 
minor  one,  linear  osteotomy 
will  suffice  for  the  rectifica- 
tion. 

The  General  BemarTcs. — 
Care  must  be  observed  that 
the  osteotome  does  not  in- 
vade the  popliteal  space  as 
the  vessels  and  nerves  may 
be  directly  injured  thereby, 
or  from  the  resulting  sharp 
fragments  of  bone.  In  the  case  of  fibrous  anchylosis  the  use  of  the  weight 
and  pulley  should  be  employed  to  overcome  as  much  as  possible  the  de- 
formity, and  also  to  stretch  to  the  fullest  extent  the  opposing  soft  parts 
before  osteotomy  is  done.  In  no  instance,  either  before  or  after  operation, 
should  these  tissues  be  so  stretched  as  to  imperil  their  integrity,  benumb 
the  limb,  or  interfere  materially  with  the  circulation.  Cuneiform  division 
is  practiced  here  with  the  saw,  especially  when  done  through  the  joint. 

Genu  Valgum. — The  opera- 
tions for  the  relief  of  genu 
valgum  can  be  practiced  with 
comparative  impunity  in  the 
presence  of  antiseptic  meas- 
ures and  anatomical  knowl- 
edge (Fig.  460).  Care  should 
be  taken  to  avoid  the  popliteal 
vessels,  especially  the  anasto- 
motica  magna  and  superior 
internal  articular  arteries. 

The  Anatomical  Points. — 
The  limit  of  the  epiphyseal 
junction  is  on  a  line  with  the 
tubercle  of  the  adductor  mag- 
nus.  The  preponderance  of 
the  bony  structure  here  corre- 
sponds to  the  external  surface 
( Fig.  461 ) .  The  synovial  mem- 
brane of  the  knee  joint  ex- 
tends upward  above  the  articular  surface  for  an  inch  or  more  with  the  limb 
extended. 


Genu  valgum. 


OPERATIONS  ON  BONES. 


443 


The  Operation  of  Osteoiomy  of  Genu  Valgum,  Supracondyloid  (Mac- 

cwen). — Flex  the  le^^  on  the  thigli  to  draw  down  the  synovial  pouch;  place 

the  limh  on  a  sand  pillow ;  make  an  incision  down  to  the  bone  through  the 

soft  parts  at  the  inner  side  of  the  limb,  beginning  a  finger's  breadth  above  the 

insertion  of  the  tendon  of  the  adductor  magnus  into 

the  spine  at  the  upper  portion  of  the  internal  condyle 

and  half  an  inch  in  front  of  the  tendon,  and  carry  it 

d   upward  sufficiently  to  admit  the  osteotome;  or,  the 

lowest  limit  is  made  to  correspond  to  a  line  drawn 

transversely  across  the  limb  in  front,  beginning  an  inch 

above  the  external  condyle,  which  will,  if  the  internal 

condyle  be  much  elongated,  prevent  the  osteotome  from 

being  driven  into  the  external  condyle  instead  of  above 

it.     The  course  of  the  incision  (Fig.  462,  a)  avoids  as 


Fig.  461.  —  Transverse 
section  near  epi- 
physeal junction  at 
lower  end  of  femur. 
a.  Anterior  surface. 


b.  External  surface,  f^j.  ^g  possible  any  interference  with  the  anastomotica 

c.  rosterior  surface.  '■ 

d.  Internal  surface,    ^i^wg' 


magna  and  the  articular  branches.  The  osteotome 
may  be  applied  to  the  bone  transversely  at  the  site 
indicated  by  the  transverse  dotted  line  (6),  and  so  directed  that  its  course 
will  correspond  to  a  line  extending  across  the  posterior  aspect  of  the 
femur  to  a  point  one  finger's  breadth  above  the  external  condyle.  The 
extent  of  the  osseous  incision  will  depend  upon  the  density  of  the  bone; 
if  the  subject  be  young,  the  bone  can  be  cut  through  two  thirds  of  its  diam- 
eter, and  then  be  bent  or  broken ;  if  it  be  dense,  it  will  be  necessary  to  carry 
the  incision  to  the  outer  wall.  The  posterior  and 
inner  surfaces  of  the  bone  are  first  cut,  when,  if  neces- 
sary, a  thinner  chisel  is  employed  to  complete  the  oper- 
ation. When  the  bone  is  sufficiently  divided,  the  limb 
is  straightened,  all  hemorrhage  arrested,  and  the  part 
treated  as  indicated. 

Fig.  463  shows  the  long  internal  condyle  of  genu 
valgum;  Fig.  464  represents  a  section  of  about  three' 
fifths  of  the  diameter;  Fig.  465  illustrates  the  ap- 
pearance of  the  bone  with  the  line  of  section  closed, 
showing  the  curvature  as  rectified.  The  prognosis  of 
this  operation,  with  reference  to  usefulness  of  the 
liml),  cure  of  the  deformity,  and  danger  to  life,  is  most 
flattering. 

The  Results. — In  about  six  hundred  and  fifty  supra- 
condyloid osteotomies  but  three  fa'tal  cases  are  reported 
that  can  be  attril^uted  to  the  operation :  one  each  from 
septicaemia,  haemorrhage,  and  carbolic-acid  poisoning. 
All  the  patients  were  benefited,  and  many  were  en- 
abled to  take  an  active  part  in  affairs  from  which  they  had  been  deljarred. 

The  Operation  of  Osteo-artlirotomy  for  Genu  Valgum  (Ogston). — The 
operation  of  osteo-arthrotomy  consists  in  dividing  the  elongated  condyle  of 
the  femur  by  sawing  (Ogston),  or  hy  cutting  (Eeeves),  sufficiently  to  admit 
of  the  rectification  of  the  deformity  (Figs.  466  and  467). 


Fig.  462. — Supracondy- 
loid osteotomy,  a. 
Direction  of  incision 
of  soft  parts,  h.  Line 
of  bone  section,  c. 
Epiphyseal  junction. 
d.  Epiphysis. 


4M 


OPERATIVE  SURGERY. 


The  Operation  hy  Saiuing. — Place  the  patient  in  the  dorsal  position;  flex 
the  leg  upon  the  thigh  fully.  At  a  point  two  or  three  inches  above  the  tip 
of  the  inner  condyle  introduce  a  tenotome  upon  the  flat,  carry  it  down- 
ward, forward,  and  outward  until  its  point  can  be  felt  anteriorly  in  the  inter- 


FiG.  463.  Pig.  464.  Fig.  465. 

Figs,  463,  464,  465.— Maeewen's  method. 


Fig.  466.  Fig.  467. 

Figs,  466,  467.— Ogston's  method. 


condyloid  space.  The  cutting  edge  is  then  turned  downward,  and  the  tissues 
divided  down  to  the  bone  as  it  is  withdrawn.  A  small  Adams's  saw  is  then 
introduced  along  the  course  of  the  incision,  and  the  condyle  is  sawed,  from 
above  downward,  and  before  backward,  through  about  three  quarters  of  its 
thickness.  If  the  limb  be  now  straightened,  the  remaining  portion  is  frac- 
tured and  the  deformity  is  rectified. 

The  Results. — In  forty-six  operations  two  patients  have  died  of  septi- 
cEemia.     Neither  of  these  methods  can  be  advised. 

The  Operation  hy  Cutting. — By  this  method  the  elongated  condyle  is 
divided  or  loosened  with  a  chisel  or  osteotome,  the  intention  being  to  divide 
the  condyle  to  the  greatest  depth  without  opening  into  the  joint.  Even 
though  the  cut  be  made  to  meet  this  indication,  the  joint  is  no  doubt  in- 
volved (except  possibly  in  the  very  young) 
by  the  displacement  upward  of  the  frag- 
ment necessary  to  correct  the  deformity. 

Chiene's  Method  of  Osteo-arthrotoniy. — 
Mr,  Chiene,  instead  of  sawing  or  cutting  off 
the  condyle,  corrected  the  deformity  by  the 
removal  of  an  oblique  transverse  wedge  of 
bone  from  the  body  of  the  condyle,  which, 
when  pressed  upward  by  straightening  the 
limb,  remained  attached  by  its  apex  to  the 
shaft  (Fig.  468).  Not  infrequently,  how- 
ever, the  condyle  is  detached  by  this  manipu- 
lation and  the  joint  opened.  The  details 
attending  this  method  are  omitted,  since  it  can  not  be  compared  favorably 
with  the  much  simpler  and  equally  efficient  one — supracondyloid  osteotomy. 

Genu  Varum.— This  deformity,  too,  is  relieved  by  osteotomy.    In  osteotomy 
in  these  instances  the  operative  proceedings  are  directed  to  the  outer  instead 


Fig.  468.— Chiene's  method. 


OPERATIONS  ON  BONES. 


445 


of  the  inner  side  of  the  bones  of  the  leg  and  thigh.  The  procedure,  pre- 
cautions, and  treatment  are  like  those  for  genu  valgum.  The  division  of  the 
bone  through  a  small  external  opening  can  be  made  almost  indiscriminately 

in  such  as  present  this  deformity, 
always  remembering  that  thorough 
and  complete  antiseptic  precautions 
shouM  be  taken. 

The  results  are  most  flattering  and 
commend  this  operation  to  the  con- 
sideration and  practice  of  the  profes- 
sion. 

Genu  Varum  (Fig.  469)  or  Bowlegs 
may  depend  on  an  outward  curvature 
of  the  bones  of  the  leg,  wholly  or  in 
part.    In  either  instance  the  deform- 
ity of  the  leg  can  be  corrected  by  oste- 
otomy of  the  tibia.     The  tibia  and 
fibula  can  be  divided  at  any  part  of 
their  course  by  either  the  linear  or 
cuneiform   methods;   the   linear    for 
the  lesser,  and  the  cuneiform  for  the  greater,  degrees  of  deformity,  is  the 
rule.     If  the  patient  be  young  enough,  a  green-stick  fracture  of  the  fibula 
will  obviate  the  necessity  for  its  division. 

The  OjJerafion  by  the  Linear  Method. — Cleanse  the  part  thoroughly,  apply 
the  elastic  bandage,  place  the  limb  on  the  sandbag,  and  at  the  point  of  the 


Fig.  469. — Genu  varum. 


Fig.  470. — Linear  osteotomy:  c.   Bone  divided,     d.    Deformity  corrected.      Cuneiform 
osteotomy  :  o.  Cuneiform  piece  removed,    i.  Deformity  corrected. 

greatest  curvature  make  a  longitudinal  incision  down  to  the  periosteum, 
midway  between  the  borders  of  the  subcutaneous  surface  of  the  tibia  at  the 


446 


OPERATIVE  SURGERY. 


point  of  proposed  division  and  of  ample  length  to  admit  the  osteotome,  which 
is  then  turned  so  as  to  divide  the  bone  transversely  sufficiently  to  admit 
of  its  being  fractured  (Fig.  470,  c,  d).  Cut  or  bend  the  fibula,  correct  the  de- 
formity, close  the  wound  in  the  soft  parts  with  catgut,  dress  antiseptically, 
and  confine  the  limb  in  a  temporary  dressing  until  all  danger  of  hgemor- 
rhage,  inflammation,  etc.,  has  subsided,  when  it  may  be  placed  in  an  immov- 
able plaster-of-Paris  dressing  and  retained  until  union  has  taken  place.  If ' 
a  double  section  is  to  be  made  at  different  points,  an  antiseptic  sponge  (Fig. 
450,  I,  m)  should  be  bound  over  the  incision  in  the  soft  parts  of  the  first 
while  the  second  operation  is  being  made.  This  affords  an  opportunity  to 
determine  the  severity  of  the  hsemorrhage  and  the  ease  with  which  it  can  be 
controlled.  If  it  be  necessary  to  divide  one  bone  in  two  situations  to  correct 
a  deformity,  the  second  division  should  be  deferred  until  the  former  has 
healed,  when  it  should  be  done  at  the  remaining  point  of  greatest  convexity. 
The  Operation  ly  the  Cuneiform  Method. — If  the  bones  be  much  curved, 
it  may  become  necessary,  in  order  that  the  deformity  be  properly  corrected, 

to  remove  a  wedge-shaped 
piece  (Fig.  470,  a,  h),  which 
is  best  accomplished  with  the 
chisel.  The  base  of  the  cu- 
neiform section  corresponds 
to  the  crest  of  the  tibia  and 
the  apex  to  the  posterior  sur- 
face, or  as  much  farther  in 
front  of  it  as  the  surgeon's 
idea  of  fracture  versus  sec- 
tion may  suggest.  The  rule 
for  the  formation  of  the 
proper  sized  section  is  indi- 
cated in  the  consideration  of 
the  treatment  of  anchylosis 
of  the  knee. 

The  After-treatment  and 
Besults. — All  osteotomies  should  be  performed  under  strict  antiseptic  pre- 
cautions, and  the  incision  of  the  soft  parts  closed  with  a  catgut  suture. 
The  limb  must  be  immovably  fixed  and  the  patient  kept  quiet;  in  fact, 
the  measures  applicable  to  a  compound  fracture  are  in  order,  since  oste- 
otomy resembles  that  condition  more  nearly  than  any  other. 

The  Results. — The  results  of  all  osteotomies  performed  with  antiseptic 
precautions  are  extremely  satisfactory.  As  yet,  I  have  no  personal  knowl- 
edge of  a  death  from  the  operation,  and  of  fourteen  hundred  osteotomies 
but  about  one  per  cent  only  are  reported  to  have  died  in  consequence  of  it. 

Hallux  Valgus. — Hallux  valgus  is  practically  limited  to  the  great  toe, 
and  is  usually  caused  by  improperly  fitted  boots  and  shoes.  Fig.  471  (Tubby) 
represents  the  condition  more  graphically  than  words  can.  In  this  con- 
dition the  first  phalanx  (anatomical)  articulates  with  the  outer  portion  of 
the  distal  extremity  of  its  metatarsal  bone  and  is  rotated  inward  on  its  long 


Fig.  471.— Hallux 


OPERATIONS  ON  BONES.  447 

axis.  The  principal  portion  of  the  head  of  the  metatarsal  hone  projects  in- 
ward, and  its  extremity  is  surmounted  hy  a  sensitive  hunion.  The  indication 
is  to  place  the  toe  in  its  normal  axis  and  retain  it  in  that  position.  In  pro- 
nounced cases  this  can  not  be  accomplished  without  division  at  the  least  of 
restraining  fibrous  tissues.  If  the  deformity  be  great,  little  else  than  an 
operation  on  the  bone  will  be  of  any  practical  value.  Two  methods  of  oper- 
ation can  be  recommended: 

1.  The  removal  of  the  head  of  the  metatarsal  bone,  together  with  enough 
of  the  shaft  to  permit  the  great  toe  to  be  easily  replaced  and  held  in  its  normal 
axis  (Fig.  -1:23,  a).  Under  strict  antiseptic  precautions  this  operation  results 
in  quick  recoveries  and  useful  toes. 

3.  The  deformity  can  be  corrected  by  removing  a  A^-shaped  piece  (cunei- 
form osteotomy)  from  the  inner  portion  of  the  distal  extremity  of  the  meta- 
tarsal bone,  as  near  the  head  as  possible  without  involving  the  joint  cavity. 
This,  too,  must  be  done  under  strict  antiseptic  precautions,  and  is  accom- 
plished through  an  incision  made  along  the  inner  side  of  the  metatarsal 
bone.  The  soft  parts  are  retracted,  and  the  V-shaped  piece  of  the  bone  is 
removed  without  dividing  more  than  three  quarters  the  diameter  of  the  shaft. 
The  thickness  of  the  base  of  the  triangular  piece  to  be  removed  is  estimated 
by  the  degree  of  deflection  of  the  toe  from  its  normal  position,  in  the  man- 
ner practiced  for  cuneiform  osteotomy. 

The  bone  wedge  can  be  removed  by  means  of  a  saw  or  chisel  and  the  toe 
brought  into  position,  causing  fracture  of  any  undivided  portion  of  the  bone. 
Horsehair  drainage  and  immobility  under  antiseptic  dressings  will  be  fol- 
lowed by  speedy  union  and  a  satisfactory  recovery.  If  the  deformity  be  less 
marked,  then  a  simple  linear  osteotomy,  followed  by  a  rectification  and  con- 
finement, will  secure  a  satisfactory  outcome.  The  author  has  on  three  occa- 
sions operated  on  both  toes  simultaneously,  employing  excision  of  the  head 
of  the  bone  and  cuneiform  osteotomy  in  proportionate  instances.  They 
all  healed  promptly,  each  resulting  in  a  serviceable  limb  with  no  appreciable 
difference  except  that  the  cases  treated  by  osteotomy  were  followed  by  freer 
movement. 

Osteotomy  for  Talipes. — The  operation  methods  devised  for  remedying 
the  deformities  of  talipes  are  quite  numerous,  and  often  as  fanciful  as  those 
directed  to  amputation  at  the  shoulder  joint.  The  following  only  will  be 
considered  as  representative  of  the  series. 

Cuneiform  Osteotomy  of  the  Tarsus  for  Talijjes  Equino-varus  (Tarsec- 
tomy,  Davies-CoUy).  The  Operation. — After  careful  antiseptic  preparation 
and  application  of  the  elastic  bandage,  place  the  foot  on  a  sand  bag,  with  the 
outer  border  uppermost ;  make  a  straight  incision  down  to  the  bone  along 
this  border  from  the  middle  point  of  the  os  calcis  to  the  base  of  the  fifth 
metatarsal  bone  ;  make  a  second  incision  through  the  superficial  tissues  from 
the  dorsum  of  the  foot  to  the  center  of  and  at  right  angles  with  the  first  an 
inch  in  length.  Eefiect  the  fiaps,  draw  aside  the  tendons  and  vessels  upon 
the  dorsal  and  plantar  surfaces,  raise  the  periosteum,  and  remove  with  saw 
or  chisel  a  wedge-shaped  piece,  composed  of  adjoining  portions  of  the  os 
calcis  and  cuboid,  and,  if  the  case  be  severe,  the  entire  cuboid  and  even  the 


448  OPERATIVE  SURGERY. 

base  of  the  fifth  metatarsal  bone.  After  removal  of  the  bone,  arrest  hgemor- 
rhage,  rectify  the  deformity,  unite  the  borders  of  the  wound,  dress  antisep- 
tically,  and  confine  the  part  in  an  immovable  position  with  a  plaster- of- Paris, 
or  other  suitable  splint. 

The  Comments. — It  is  thought  better  that  the  second  incision  pass  into 
the  sole  of  the  foot  rather  than  onto  the  dorsum  (Tubby).  The  primary  in- 
cision should  be  extended  downward  sufficiently  to  meet  the  operative  re- 
quirements of  the  deformity.  Since  the  cause  of  the  deformity  exists  at  the 
inner  aspect  of  the  foot,  and  the  effect  at  the  outer,  the  removal  of  the  bone 
at  the  latter  situation  can  not  be  regarded  as  rational  except  as  a  final 
expedient. 

The  Results. — In  about  ten  per  cent  of  the  cases  suppuration  has  oc- 
curred, followed  by  death  in  one  instance.  The  operation  should  not  be 
practiced,  except  as  a  final  resort,  and  then  with  certain  antiseptic  technique. 

The  Operation  of  Linear  Osteotomy  of  the  Neck  of  the  Astragalus  for 
Talipes  Equino-varus  (Bradford). — This  operation  is  not  attempted  until 
after  the  beneficial  effects  of  division  of  contracted  tissues  and  manipulation 
have  failed  to  correct  the  deformity. 

The  Operation. — After  strict  antiseptic  preparation  and  application  of 
the  elastic  bandage,  make  an  incision  through  the  soft  parts  from  the  top  of 
the  inner  malleolus  to  the  inner  border  of  the  head  of  the  first  metatarsal 
bone ;  draw  apart  the  borders  of  the  opening,  adduct  the  foot  strongly,  and 
expose  the  scaphoid  bone  and  the  head  and  neck  of  the  astragalus ;  intro- 
duce and  place  an  osteotome  across  the  inner  aspect  of  the  neck  of  the  as- 
tragalus and  sever  it  with  a  few  sharp  blows  of  the  mallet.  If  the  bone  be 
incompletely  severed,  the  rectification  of  the  deformity  will  cause  fracture 
of  the  remaining  portion.  Correct  the  malposition  of  the  foot,  unite  the 
borders  of  the  wound,  dress  antiseptically,  and  confine  the  part  in  position 
until  union  occurs. 

The  Remarks. — The  line  of  section  of  the  neck  should  be  in  a  plane  such 
that  when  the  deformity  is  corrected  the  gap  at  the  site  of  section  will  be 
of  the  smallest  possible  size.  Although  simple  in  practice  this  plan  often 
proves  inefficient. 

Phelps's  Open  Incision  Method. — The  free  open  incision  method  is  prac- 
ticed when  the  integument  at  the  seat  of  the  deformity  is  too  short  to  permit 
of  rectification  after  a  free  subcutaneous  division  of  the  constricted  tissues. 

The  Operation. — After  the  employment  of  thorough  antiseptic  precau- 
tions and  the  application  of  the  elastic  bandage^,  make  an  incision  beginning 
directly  in  front  of  the  inner  malleolus  and  passing  downward  to  the  inner 
side  of  the  neck  of  the  astragalus.  Through  this  incision  divide  respect- 
ively such  of  the  following  structures  as  offer  resistance  to  the  rectification 
of  the  deformity:  the  tendon  of  the  tibialis  posticus  muscle,  the  abductor 
poUicis  muscle,  flexor  brevis  digitorum  muscle,  tendons  of  long  flexor 
muscles,  the  elongations  of  the  deltoid  ligament  and  of  the  plantar  fascia, 
and  the  calcaneo-scaphoid  ligament,  avoiding  if  possible  the  internal  plantar 
nerve  and  artery.  The  wound  should  be  dressed  to  secure  organization  of 
blood  clot  (page  358)  if  possible,  or  treated  in  the  usual  manner  of  open 


OPERATIONS  ON  BONES. 


4-49 


Fig.  472. — Phelps's  operation,  four  weeks  after. 


wounds.  At  once  or  a  few  days  later  the  raw  surface  may  he  covered  with 
skin  grafts.  Fit  dps  advises  that  if  the  clastic  constriction  l)o  employed  the 
dressing  he  applied  he- 
fore  its  removal,  and 
that  the  extremity  he 
slung  in  a  perpendicu- 
lar position  for  from 
four  to  six  hours  there- 
after. The  deformity 
must  he  corrected  he- 
fore  application  of  the 
dressing,  and  he  im- 
movahly  confined  in 
the  rectified  position 
hy  plaster  of  Paris  or 
other  acceptahle  means. 

The  Besulis.  — 
Phelps  reports  one 
hundred  and  sixty-one 
operations,  of  which 
ten  cases  were  found 
to  have  relapsed  one  year  after,  due,  it  is  claimed,  to  neglect.  The  cases  heal 
promptly  with  hut  few  exceptions,  and  serviceahle  limhs  are  secured 
(Fig.  472). 

The  Enucleation  of  the  Astragalus  (Lund) . — This  procedure  is  practiced, 
and  with  much  success,  in  inveterate  cases  of  cluhfoot.  As  the  method  of 
excision  has  heen  described  already  (page  410)  nothing  further  need  he 
added  at  this  time,  except  that  the  foot  he  confined  immovably  at  right 
angles  with  the  leg  until  healing  is  complete. 

The  Results. — In  twenty-one  cases  all  did  w-ell.  In  two  suppuration 
occurred. 

Other  operative  methods  are  employed  for  the  relief  of  talipes,  as,  for  in- 
stance, through  an  incision  extending  from  the  front  of  the  lower  end  of  the 
internal  malleolus  to  the  internal  cuneiform  hone,  a  wedge-shaped  piece  of 
hone  can  he  taken  from  the  inner  border  of  the  foot  formed  of  the  scaphoid 
alone  or  including  the  head  of  the  astragalus  (Bird),  or  the  astragalo-scaphoid 
joint  may  he  excised  or  erasion  practiced  upon  it  in  such  a  manner  as  to 
form  a  wedge-shaped  space  (Ogston).  Eecently  the  removal  of  the  astragalus 
has  heen  practiced  successfully  (Vogt).  Each  of  the  aforegoing  methods 
has  heen  employed  with  varying  success  for  the  relief  of  flat  foot.  In  either 
instance,  after  operation  the  foot  is  corrected  and  held  properly  in  place  with 
pegs,  wire,  etc.,  or,  what  is  still  better,  a  properly  moulded  plaster-of -Paris 
splint.  The  removal  of  a  wedge-shaped  piece  of  hone  from  the  inner  side 
of  the  head  and  neck  of  the  astragalus  (Stokes),  followed  hy  correction  and 
the  usual  treatment  of  these  operations,  is  a  useful  expedient  for  the  relief 
of  talipes  valgus.  The  treatment  applicable  to  compound  fractures  should, 
furthermore,  he  addressed  to  each  of  these  operations. 


450  OPERATIVE  SURGERY. 

Osteoplasty. — Osteoplasty  or  transplantation  of  bone  has  not  yet  gained 
the  prominence  as  a  general  surgical  expedient  that  the  knowledge  of  the 
laws  governing  the  growth  of  bone  seemed  likely  to  secure  for  it. 

Bone  along  with  its  periosteal  and  fibrous  connections  has  been  pushed 
to  one  side — transverse  displacement — as  in  the  case  of  the  operation  on  the 
hard  palate  for  the  closure  of  a  fissure.  The  closure  of  the  spaces  between 
fragments  and  borders  of  bone,  by  filling  such  spaces  with  freshly  sawed 
sections  from  the  main  structure  with  bone  chips,  or  decalcified  bone  frag- 
ments, is  in  many  instances  wisely  and  successfully  practiced.  The  condi- 
tions necessary  for  a  successful  issue  are  numerous  and  exacting,  the  chief 
one  of  which  is  a  most  rigid  adherence  to  the  antiseptic  methods. 

In  the  employment  of  bone  chips,  whether  decalcified  or  not,  the  intra- 
vention  and  organization  of  blood  clot  is  essential  to  success.  The  tech- 
nique of  this  procedure  is  the  following : 

The  Preparation  of  the  Bone. — Saw  into  longitudinal  strips  about  an 
eighth  of  an  inch  in  thickness  the  compact  tissue  of  the  tibia  or  femur  of  the 
ox,  entirely  stripped  of  periosteal  and  marrow  tissue ;  immerse  the  bone  strips 
in  a  ten-  to  fifteen-per-cent  solution  of  hydrochloric  acid  and  water,  which 
is  changed  daily  for  from  one  to  two  weeks ;  then  wash  the  strips  in  a  weak 
alkaline  solution;  cut  into  small  pieces,  and  immerse  them  for  forty-eight 
hours  in  a  l-to-1,000  bichloride  solution,  after  which  store  them  finally  in  a 
saturated  solution  of  iodoform  and  ether. 

The  Preparation  of  the  Cavity. — Cleanse  the  cavity  by  thorough  and 
repeated  curetting  and  fiushing  with  a  l-to-2,000  bichloride  solution  supple- 
mented by  scouring  with  aseptic  gauzfe  and  dusting  with  iodoform.  If  the 
cavity  be  filled  with  olive  oil  and  the  oil  be  raised  to  a  boiling  point  by  the 
introduction  of  a  thermo-cautery,  the  cavity  is  made  aseptic. 

The  Filling  of  the  Cavity  ivith  the  Chips. — Place  a  capillary  drain  at  the 
most  dependent  point  of  the  cavity;  carefully  fill  the  latter  with  the  bone 
chips  and  unite  the  soft  parts  over  them  with  buried  and  subcuticular  su- 
tures and  dress  antiseptically.  Before  using,  the  bone  chips  of  proper  size  to 
fit  the  cavity  should  be  selected,  wrapped  in  aseptic  gauze,  and  immersed  in 
alcohol  to  remove  the  ether  and  iodoform.  Just  before  using,  they  are 
washed  in  a  l-to-1,000  bichloride  solution,  and  cautiously  wiped  with  iodo- 
form gauze.  If  employed  in  cranial  openings,  they  should  be  freely  per- 
forated to  hasten  drainage.  If  the  soft  parts  be  too  scanty  to  cover  the 
grafts,  aseptic  rubber  tissue  should  be  employed  to  remedy  the  defect. 

The  feasibility  of  bone  transplantation  en  masse  is  not  yet  sufficiently 
established  to  warrant  its  being  considered  a  matter  of  great  practical  utility. 


CHAPTER   IX. 

AMPUTA  TIONS.— GENERA  L   CONS  ID  ERA  TIONS. 

Amputation"  consists  in  the  cutting  off  of  a  limb  in  the  continuity  of 
the  bone  structure  or  at  an  articulation  ;  the  latter  is  often  termed  disarticula- 
tion. The  aims  sought  for  in  amputation  are  :  1.  The  saving  of  the  life  of 
the  patient.  2.  The  securing  of  a  serviceable  stump.  If  the  prospects  of 
recovery  be  annulled  by  the  presence  of  a  badly  diseased  or  a  mangled  limb, 
it  is  no  opprobrium  to  the  art  of  surgery  to  remove  the  limb.  If  a  limb  be 
so  badly  injured  or  diseased  as  to  require  removal,  it  is  wise  that  the  me- 
chanical ability  of  the  designer  of  compensative  appliances  be  considered,  so 
that  the  patient  may  reap  the  combined  benefit  of  the  art  of  the  surgeon 
and  the  ingenuity  of  the  mechanic. 

A  stump,  to  he  serviceable,  should  he  sound,  unirritahle,  with  good  circii- 
latioti  and  abundant  leverage.  The  first  three  qualities  depend  very  largely 
upon  the  length,  shape,  vascular  supply,  and  sensibility  of  the  flaps ;  the 
last  one  depends  entirely  upon  the  length  of  the  bone.  The  flaps  at  the 
extremity  of  the  stump  after  healing  is  completed  should  be  freely  movable 
— except  at  the  seat  of  the  cicatrix — over  the  subjacent  tissues,  not  tightly 
drawn  and  smooth  like  a  baseball  cover.  Flaps  that  are  tightly  drawn  at  the 
initial  dressing  soon  become  more  tense,  on  account  of  tissue  retraction  and 
inflammatory  action.  The  increased  tension  causes  pain,  early  and  rapid 
ulceration  at  the  seat  of  the  sutures,  followed  by  separation  of  the  flaps, 
union  by  granulation  with  a  broad  scar,  and  finally  a  troublesome  stump  ;  or 
the  normal  shrinkage  of  the  integument  draws  the  fiaps  against  the  end  of 
the  bone,  to  which  they,  together  with  the  cicatrix,  become  immovably  united, 
causing  similar  difficulties.  Integument  normally  exposed  to  pressure — as 
that  of  the  palm  of  the  hand  and  sole  of  the  foot — makes  the  best  covering. 
The  proper  length  of  flaps,  therefore,  becomes  an  important  point  in  estimat- 
ing the  prospective  usefulness  of  the  limb  and  the  comfort  of  the  patient. 
As  a  general  proposition,  in  flap  amputation  both  flaps  should  be  made  the 
same  length,  each  equaling  not  less  than  one  fourth  the  circumference  of 
the  limb  at  the  point  where  the  bone  is  to  be  divided.  If  one  flap  only  is 
employed  it  should  equal  in  length  the  two  flaps.  Any  decrease  in  the 
length  of  one  flap  should  be  accompanied  by  a  proportionate  increase  in  the 
length  of  the  other.  The  lengths  of  the  flaps  control  largely  the  site  of  the 
cicatrix.  It  is  advisable  that  the  cicatrix  he  so  placed,  when  practicable,  as 
not  to  be  subjected  to  undue  pressure  or  friction.  If,  however,  the  flaps 
be  made  of  sufficient  length  to  admit  of  the  formation  of  a  non-adherent 
451 


452  OPERATIVE  SURGERY. 

or  movable  cicatrix,  its  location  is  a  matter  of  secondary  importance.  The 
length  and  situation  of  the  flaps  largely  influence  their  circulation.  If  they 
are  too  long,  the  circulation  will  be  enfeebled  ;  if,  on  the  contrary,  they  are 
too  short,  it  will  be  impeded  by  the  tension,  causing  in  either  instance  a 
blue,  cold,  and  shiny  surface  sensitive  to  the  slightest  injury.  While  the 
general  rules  just  stated  are  a  fair  guide  in  establishing  the  proper  length 
of  flaps,  still  it  is  necessary  not  to  lose  sight  of  the  fact  that  certain  natural 
and  acquired  characteristics  of  the  structure  of  a  stump  so  modify  its  useful- 
ness as  to  compromise  the  result  of  amputation  unless  these  characteristics 
be  given  due  recognition  at  the  time  of  operation.  The  contractility  of 
the  integument  and  subcutaneous  tissue  is  lessened  by  infiltration  of  inflam- 
matory products,  overdistention,  old  age,  and  atrophy.  Integument  thick- 
ened by  friction,  or  naturally  dense,  contracts  but  little.  On  the  other 
hand,  if  the  integument  be  thin,  or  have  scanty  subcutaneous  tissue,  or  be 
disconnected  from  bony  or  abnormal  subjacent  structure,  the  contraction  is 
well  marked.  It  is  a  matter  of  common  observation  that  muscles  contract 
when  severed.  The  amount  of  their  shortening  is  influenced  by  the  length, 
size,  vigor,  and  freedom  of  the  muscle.  Short,  small,  weak,  or  atrophied 
muscles,  and  those  of  limited  movement,  contract  comparatively  little.  The 
degree  and  duration  of  primary  and  secondary  muscular  retraction  often 
modify  the  final  aspects  of  a  stump,  as  will  appear  hereafter  in  the  con- 
sideration of  special  amputations.  The  nutritive  integrity  of  a  flap  and 
the  freedom  of  the  circulation  are  enhanced  by  attention  to  the  proper 
degree  of  arterial  supply  and  care  in  the  preservation  of  the  vessels.  A  too 
great  compression  with  bandages,  a  vigorous  bending  or  the  undue  traction 
of  a  flap  to  bring  it  into  position,  contribute  fatally  often  to  the  integrity  of 
the  structure.  The  severed  ends  of  tendons  should  not  extend  below  the 
division  of  the  remaining  soft  parts,  nor  should  they  be  cut  so  short  as  to 
cause  the  empty  sheaths  to  harbor  deleterious  products.  The  nerves  should 
te  severed  high  enough  to  prevent  their  ends  entering  directly  into  the  cica- 
tricial and  reparative  tissue  at  the  end  of  the  stump.  The  periosteum  should 
te  neither  bruised  nor  lacerated,  but  cut  neatly  through  at  the  point  of  bone 
section.  The  hone  itself  should  he  sawed  caref^illy  and  squarely  and  not 
denuded  of  periosteum,  otherwise  circumscribed  necrosis  will  occur.  The  re- 
moval of  the  cicatrix  from  direct  pressure  irritation  suggests  that  those  of 
the  lower  extremity  have  a  lateral,  and  those  of  the  upper  a  central  location. 
However,  it  should  not  be  forgotten  that,  notwithstanding  the  exercise  of 
the  greatest  care  in  each  of  the  foregoing  respects,  an  untidy  stump,  or  one 
belonging  to  a  dissipated  person,  is  very  liable  indeed  to  become  the  cause  of 
great  annoyance,  if  not  of  physical  incapacity.  The  circulation  even  in  a 
normal  limb,  or  a  portion  of  it,  may  be  such  as  to  predispose  to  a  small 
and  sluggish  blood  supply  and  thus  impair  flaps  constructed  from  it. 

The  flaps  are  dassifled^  according  to  the  kind  of  tissues  entering  into  them, 
as  the  cutaneous  or  integumentary  or  sTcin  flaps,  musculo-cutaneous,  and 
periosteal,  either  variety  of  which  may  be  single  or  double.  The  integumen- 
tary variety  is  commonly  employed  in  this  country.  The  outlines  and  struc- 
ture of  flaps  have  been  changed  so  often,  and  yet  so  slightly  on  the  whole,  that 


AMPUTATIONS. 


453 


it  is  difficult  indeed  to  assign  rational  reasons  for  the  multiplication  of  terms 
and  methods  born  of  these  alterations.  Which  makes  the  better  flap,  the  skin 
and  subcutaneous  tissue  alone  or  when  combined  with  muscular  tissue,  is  not 
yet  definitely  settled.  It  is  fair  to  say,  however,  that  the  flaps  of  skin  are  less 
vital  than  when  fortified  with  subjacent  muscular  structure.  However,  this 
fact  is  not  of  great  significance  except  in  the  enfeebled  circulation  of  the  old, 
or  in  the  presence  of  the  necessity  for  an  inordinately  long  flap.  While  it  is 
true  that  the  muscular  tissue  of  a  flap  soon  atrophies,  yet  it  can  not  be 
denied  that  the  fibrous  residue  of  the  muscle  exercises  a  serviceable  influence 
at  the  end  of  the  stump.  At  all  events,  the  integumentary  portion  should 
be  considerably  longer  than  the  muscular  part.  Surely  there  can  be  but 
little  doubt  of  the  fact  that  the  dangers  incident  to  infection  are  less  pro- 
nounced in  integumentary  than  in  muscular  flaps. 

Flaps  are  fashioned  by,   1,  transfixion,  2,  by  free   deep  cutting  from 
without,  and,  3,  by  superficial  division  and  separation  of  their  tissues.     The 


Fig.  473.— Circular  method. 


first  two  methods  provide  musculo-cutaneous  flaps,  the  last  one  integumen- 
tary. The  novice  in  surgery  and  the  conceited  surgeon  regard  it  as  deroga- 
tory to  their  attainments  to  trim  or  shape  a  flap  after  its  division.  It  is  far 
wiser,  however,  to  make  flaps  of  excessive  length  and  suitably  trim  them 
thereafter,  than  to  make  them  too  short  at  the  expense  of  the  comfort  and 
usefulness  of  the  limb.  The  great  danger  is  that  flaps  will  be  made  too 
short  rather  than  too  long. 

The  methods  of  amputation  are  classified.^  according  to  the  outlines  of  the 
incisions,  into  circular.,  modified  circular,  elliptical  (page  400),  oval  or  racket, 
and  common  and  special  flap  methods.  The  flaps  of  these  methods  may  be 
composed  of  integument  alone,  or  combined  with  muscular  tissue,  and  even 
with  periosteum. 

The  Circular  Method. — The  circular  method  gives  an  admirable  stump. 
It  is  easily  and  consequently  frequently  made,  and  is  recommended  especially 


454 


OPERATIVE  SURGERY. 


in  the  field  operations  of  military  surgery,  since  the  lightness  of  the  flaps 
permits  transportation  of  the  wounded  with  the  minimum  degree  of  disturb- 
ance at  the  seat  of  the  amputation.  It  is  performed  by  making  an  incision 
around  the  limb  (Fig.  473)  through  the  integument  and  subcutaneous  tissue 


Fig.  474. — How  to  dissect  up  the 


down  to  the  fascia  of  the  muscles,  at  a  distance  not  less  than  one  fourth 
the  circumference  of  the  limb  at  the  point  of  proposed  division  of  the 
bone,  and  so  directed  that  after  contraction  of  the  integument  a  circular 
flap  will  remain.  The  flap  is  then  separated  from  the  muscles  with  an 
ordinary  scalpel,  the  edge  being  directed  toward  the  muscles  (Fig.  474) 
rather  than  parallel  with  them  (Fig.  475),  so  that  the  capillary  connection 
between  the  integument  and  the  deeper  tissues  will  not  be  injured  un- 


FiG.  475.— How  not  to  do  it. 

necessarily.  The  separation  should  be  done  by  circular  sweeps  of  the  scalpel 
and  upward  traction  of  the  skin  with  the  hand,  rather  than  by  mincing 
cuts,  which  hack  the  tissues  and  hinder  union. 


AMPUTATIONS. 


45f 


If  the  limb  be  of  a  conical  shape,  much  difficulty  will  be  experienced  in 
turning  over  the  sleeve  of  integument,  whicli  can,  bowever,  be  obviated  by 
a  longitudinal  division  of  the  flap  nuide  usually  af  its  most  dependent  por- 


FiG.  476. — Division  of  the  muscles  close  to  reflection  of  flap. 


tion.  The  flap  should  be  turned  upvs^ard.  to  the  point  where  the  bone  is 
to  be  divided;  then,  with  a  suitable  knife,  make  a  circular  division  of  the 
muscles  down  to  the  bone,  beginning  far  enough  below  the  reflection  of  the 
flap  to  allow  for  the  retraction  of  the  divided  mus- 
cles. While  no  definite  law  can  be  assigned  as  a  guide 
to  this  part  of  an  amputation,  still,  as  already  stated, 
muscles  retract  according  to  their  size,  length,  degree 
of  irritability,  etc.  The  points  of  section  of  special 
muscles  will  be  stated  in  the  description  of  the  ampu- 
tations requiring  it.  Not  infrequently  the  muscles  are 
cut  just  below  the  reflection  of  the  flap,  as  in  Fig. 
476;  this  plan  is  not,  however,  as  good  as  that  in 
which  a  lower  division  is  practiced,  since  sensitive 
stumps  are  more  liable  to  result  therefrom  (Fig.  477). 
A  conical  stump  is  a  not  infrequent  sequel  of  this 
method  of  amputation,  and  is  the  result  of  an  equal 
division  of  unequally  retractile  tissues.  In  those  parts 
where  the  bone  is  located  centrally — in  the  arm  and 
thigh — the  superimposed  muscular  structure  should 
be  divided  by  repeated  circular  cuts,'  so  as  to  create  a 
funnel-shaped  stump  with  the  end  of  the  bone  at  the 
summit  (Fig.  634).  A  stump  thus  fashioned  alfords 
good  drainage,  and  reduces  the  liability  of  protrusion 
of  the  bone  to  a  minimum.  The  bone  should  be  sawed  at  its  highest  point 
of  exposure. 


Fig.  477. — Stump  after 
circular  amputation. 


456 


OPERATIVE  SURGERY. 


The  Modified  Circular  Method.— "T^ib  circular  method  may  be  modified 
by  making  one  or  more  longitudinal  incisions  through  the  integumentary 
structure  down  to  the  circular  cut.    A  posterior  longitudinal  incision  (trans- 


Fig.  478. — Modified  circular  flap. 

verse  racket  flap)  facilitates  the  turning  up  of  the  flap,  and  offers  an  ad- 
mirable opportunity  for  drainage.  An  anterior  longitudinal  incision  is  not 
to  be  commended.  One  made  at  either  side  of  the  limb  down  to  the  circular 
cut  forms  square  antero-posterior  flaps  which  possess  no  advantage  over  the 
lateral  variety. 

The  following  plan  was  suggested  by  Mr.  Listen.  He  made  semilunar 
flaps,  which  were  dissected  up  to  their  points  of  junction  with  each  other,  at 
which  level  the  muscles  and  bone  were  divided,  as  in 
the  circular  method.  Listen's  method  was  afterward 
modified  by  Mr.  Syme,  who  dissected  a  short  distance 
above  the  points  of  juncture  of  the  flaps,  and  divided  the 
muscle  and  bone  as  before  (Fig.  478) .  In  either  instance, 
however,  it  amounts  substantially  to  slitting  up  the  cuff 
of  a  circular  flap  on  opposite  sides  and  trimming  off  the 
angles  caused  thereb}^ 

The  Oval  or  Racket  Method. — The  oval  or  racket 
method  is  in  reality  a  modified  circular  amputation,  the 
flap  being  slit  up  at  one  side  and  the  angles  trimmed 
off  (Fig.  479).  This  flap  is  employed  principally  in 
disarticulations,  and  will  be  described  in  connection  with 
those  operations.  Oval-shaped  flaps  may  be  either  uni- 
lateral, bilateral,  anterior,  or  posterior. 

The  Single-flap  Method. — The  single  flap  is  suited 
to  those  cases  where  the  tissues  of  one  side  of  a  limb  only  are  available 
for  the  purposes  of  a  flap,  as  in  the  case  of  unilateral  lacerations,  ulcera- 


PiG.  479.— Racket 
flap  at  shoulder. 


AMPUTATIONS. 


457 


tions,  etc.  This  flap  may  be  composed  of  the  muscular  tissues  and  integu- 
ment, or  of  integument  alone  (Fig.  (516),  and  can  he  made  either  by  trans- 
fixion or  division  from  without.  If  possible,  a  short  convex  flap  is  made  on 
the  opposite  surface  of  the  limb. 

The  doiihle-flap  metliod  is  performed  by  transfixion,  and  includes  the 
muscles  down  to  the  bone  on  either  aspect  of  the  limb  (Figs.  480  and  481). 
The  tissues  to  be  transfixed  are  raised  slightly  by  the  left  hand  of  the 
operator,  who  then  enters  the  point  of  the  knife  at  the  side  nearest  him- 
self, pushing  it  through  slowly  in  close  contact  with  the  anterior  surface 
of  the  bone,  slightly  raising  the  handle  as  it  passes  in  front  of  the  bone, 
thereby  causing  its  point  to  emerge  at  the  opposite  side  of  the  limb  at  a 
point  exactly  opposite  to  that  of  entrance;  the  flap  is  then  made  by  cut- 
ting with  a  sawing  motion  obliquely  upward  and  forward.  This  flap  is 
pulled  backward  by  an  assistant,  and  the  knife  is  reinserted  at  the  original 
point  of  entrance,  carried  behind  the  bone,  handle  depressed  to  cause  the 


Fig.  480. — Flaps  by  transfixion. 


Fig.  481. — Removal  by  transfixion. 


point  to  emerge  at  the  same  situation  as  at  the  anterior  transfixion,  and 
the  posterior  flap  made  by  cutting  obliquely  upward  and  backward.  Each 
flap  should  correspond  in  length  to  at  least  one  half  the  diameter  of 
the  limb.  The  retractor  is  then  applied,  the  soft  tissues  are  drawn  well 
upward,  the  remaining  fibers  in  contact  with  the  bone  are  severed  by  a  cir- 
cular sweep  of  the  knife,  and  the  bone  is  carefully  sawed  through.  When 
lateral  flaps  are  made,  the  flap  containing  the  large  vessels  should  be  con- 
structed last. 

The  mixed  double  flap  is  a  modification  of  the  preceding,  and  sometimes 
called  Sedillot's  method.  The  fiaps  are  made  by  transfixion,  as  before,  but 
are  more  superficial,  the  knife  not  being  brought  in  contact  with  the  bone. 
The  remaining  muscles  and  vessels  are  divided  by  a  circular  incision,  and 
the  amputation  completed  as  before  described.  In  this  instance  the  flaps 
are  thinner  and  shorter  than  in  the  preceding. 
31 


i58 


OPERATIVE  SURGERY. 


Langenbecl^'s  ilfei/^ocZ.— Langenbeck's  method  differs  from  the  last  one 
only  in  the  manner  of  obtaining  the  resnlt,  the  flaps  being  cut  from  the  sur- 
face toward  the  center  of  the  limb,  thus  affording  a  better  opportunity  to 
shape  them.     Another  modification  of  this  method  consists  in  cutting  the 


Fig.  482.— Teale's  method. 


Fig.  483.— Teale's  stump. 


anterior  flap  from  the  surface,  and  making  the  posterior  flap  afterward  by 
transfixion. 

The  Rectangular  Flap  {Teale's  Metliod)  (Figs.  482  and  483).— In  Teale's 
method  two  rectangular  flaps  are  employed,  one  being  four  times  longer 
than  the  other;  both  flaps  include  the  structures  down  to  the  bones.  The 
longer  flap  is  taken  from  the  surface  of  the  limb  where  the  bone  is  the  most 
superficial.  The  shorter  contains  the  important  vessels.  The  length  and 
breadth  of  the  long  flap  each  equals  half  the  circumference 
of  the  limb  at  the  point  of  proposed  amputation.  The 
width  of  the  short  flap  is  a  half,  and  its  length  an  eighth,  of 
the  circumference  of  the  limb  at  the  point  of  bone  section. 
Both  flaps  should  be  carefully  marked  out  before  beginning 
the  operation.  This  method  makes  an  admirable  stump,  but 
sacrifices  fulcrumage,  and  therefore  can  be  employed  only  at 
special  parts  of  the  body,  and  when  the  tissues  at  one  aspect 
of  the  limb  only  are  healthy  and  suitable  for  flaps.  Mr. 
Lister  recommends  that  the  longer  flap  be  made  a  third  and 
the  shorter  flap  a  sixth  of  the  circumference  of  the  limb  in 
length,  thus  bringing  the  cicatrix  at  the  edge  of  the  stump ; 
also  that  the  posterior  flap  shall  consist  of  the  integument 
and  subcutaneous  tissues  alone.  Lister's,  like  Teale's,  method 
may  be  employed  when  the  loss  of  tissue  is  greater  upon 
one  side  of  a  limb  than  upon  the  other. 

Tlie  Hood  Flap. — The  hood  flap  resembles  very  closely  in- 
deed the  racket  flap  (Fig.  617).  There  is  therefore  no  sub- 
stantial difference  in  the  plan  of  construction  of  this  and 
that  of  the  circular  flap,  if  the  latter  be  slit  up  at  the  most 
dependent  part  and  the  resulting  corners  rounded  off.  This 
method  meets  the  indications  requisite  for  a  good  stump  as  well  as  any 
variety  of  flap. 

The  Equilateral  Flaps  (Fig.  484).— Equilateral  flaps  are  formed  of  skin 
and  are  oval  in  outline,  the  posterior  angle  being  located  somewhat  farther 


Fig.    484.  — Bi- 
lateral - 
method. 


AMPUTATIONS. 


459 


up  the  linil)  tlian  the  anterior,  to  improve  the  drainage.  The  muscles  are 
cut  by  a  circulai-  sweep  at  a  suitable  distance  below  the  point  of  reflection  of 
the  integumentary  flaps,  and  the  bone  is  exposed  and  sawed  somewhat  above 
the  anterior  point  of  junction  of  the  flaps. 

The  Periosteal  Flap. — A  periosteal  flap  is  properly  made  by  raising  the 
periosteum,  in  conjunction  with  the  tissues  which  rest  upon  or  are  attached 
to  it  (Fig.  038),  so  as  to  cover  the  end  of  the  divided  bone,  after  which  it  is 
allowed  to  fall  into  place.  If  a  periosteal  flap  be  raised  independently  of 
superimposed  tissues,  it  is  very  liable  to  waste  away  or  slough  outright  (Fig. 
485,  a).  This  variety  of  flap  is  adapted  best  to  those  bones  subcutaneously 
located,  like  the  tibia,  and  will  be  again  referred  to  in  connection  with  am- 
putations of  the  leg.     A  periosteal  flap  will,  if  it  become  adherent  to  the  end 

of  the  bone,  preserve  it  from  atrophy,  and  lessen 
,  the  danger  of  the  formation  of  a  conical  stump  ; 

it  likewise  prevents  the  adhesion  of  the  scar  to 
the  bone,  thereby  forming  the  basis  for  a  mova- 
ble cicatrix. 

If  the  patient  be  young,  new  bone  may  be 
developed  from  the  periosteal  fiajD,  which  will 
add  much  to  the  usefulness  of  the  stump.  It  is 
claimed  by  some  that  bony  spiculae  often  shoot 
into  the  soft  tissues  at  the  end  of  the  stump, 
and  require  a  second  operation  for  their  removal. 
It  is  our  opinion,  however,  that  if  the  perios- 
teum be  removed  entire  and  remain  connected 
with  the  superimposed  tissues,  and  be  so  placed 
that  the  force  of  gravity  will  aid  in  holding  its 
bone-producing  surface  in  contact  with  the  di- 
vided end  of  the  bone,  this  danger  will  be  obvi- 
ated. 
The  Comparative  Merits  of  Different  Forms  of  Flaps. — The  princi- 
pal aims  sought  in  making  flaps  are :  1.  To  secure  good  drainage.  2. 
To  make  the  flaps  of  suitable  length,  that  the  circulation  and  move- 
ment of  the  integumentary  cushion  at  the  end  may  be  unrestrained.  3. 
To  place  the  cicatrix  beyond  the  point  of  friction,  and  prevent  its  adhe- 
sion to  the  end  of  the  bone.  4.  To  guard  against  any  danger  of  undue 
sensibility,  by  making  the  flaps  of  proper  length,  and  by  drawing  down 
and  cutting  off  the  cutaneous  and  other  nerves  of  larger  size  that  may 
exist  in  them. 

With  these  aims  in  view,  it  will  be  seen  that  the  old-fashioned  circular 
flap  affords  equal  advantages,  in  proper  sites,  to  the  others,  and  is  commend- 
able for  its  simplicity  and  rapidity  of  execution.  It  is  true  that  in  this 
method  the  scar  will  fall  on  the  end  of  the  stump,  but  with  proper  precau- 
tions as  to  the  length  of  the  flaps  and  suitable  surgical  attentions,  any  dan- 
ger from  this  source  is  reduced  to  a  minimum.  As  Treves  very  justly  says, 
"  It  is  difficult  to  claim  an  unreserved  superiority  for  any  one  method." 
While  in  one  situation  the  circular  amputation  is  undoubtedly  the  best,  in 


Fig.  485. — Improperly  made 
periosteal  flap. 


460 


OPERATIVE  SURGERY. 


another  it  is  with  equal  certainty  the  least  efficient  method  of  procedure. 
Tlie  same  may  be  said  of  any  one  method  of  performing  amputation  by  the 
cutting  of  flaps. 

The  main  commendatory  points  in  the  selection  of  a  method  of  ampu- 
tation are  the  following :  1.  The  method  should  be  one  attended  with  the 


Fig,  486. — Instruments  employed  in  amputation. 
a.  Scalpels,  h.  Forcipressure.  c.  Thumb  forceps,  d.  Curved  and  straight  rongeurs,  e. 
Periosteotome.  /.  Lion-jaw  forceps,  g.  Liston's  bone-cutting  forceps.  A.  Aneur- 
ism needle,  i.  Rugine.  /.  Tenaculum.  Ic.  Lifting-back  and  Gigli-Haertel's  saws. 
Retractors  (page  50),  needle-holders  (page  100),  needles,  sutures,  drainage,  etc.,  are 
required. 

least  sacrifice  of  the  healthy  tissues  of  the  limb,  while  providing  a  good 
and  permanent  covering  for  the  bone.  2.  One  causing  as  small  a  wound 
area  as  is  consistent  with  its  proper  performance.  3.  One  securing  a  good 
blood  supply  to  the  flaps  and  tissues  which  form  the  stump.  4.  One  fol- 
lowed by  a  well-adjusted  and  painless  cicatrix.     Therefore  the  line  of  coap- 


AMPUTATIONS. 


461 


tation  should  be  so  placed  as  not  to  interfere  with  the  healing  process,  while 
securing  at  the  same  time  efficient  drainage,  and  removing  the  cicatrix  from 
pressure  as  far  as  possible  when  the  stump  is  healed.  5.  One  providing 
easy  exposure  of  the  bone  at  the  saw  line,  and  having  simplicity  of  method. 
•'  6.  One  permitting  of  the  cutting 

of  the  main  vessels  transversely, 
and  allowing  of  rapidity  in  the 
operation. 

Since  many  of  the  preceding 
forms  of  flaps  are  but  modifications 
of  the  circular  variety,  they  inherit 
the  advantages  of  their  distin- 
guished progenitor.  However,  the 
circular  method  is  not  the  best  if 
the  soft  parts  near  to  the  injury, 
disease,  or  distortion  be  unequally 
involved,  as  then  a  sacrifice  of  the 
healthy  tissue  of  the  opposite  side  of 
the  limb  is  required.  It  is  clearly 
obvious  that  an  irregular  flap 
method  is  suited  for  these  cases. 

The  agents  required  for  ampu- 
tation are  those  for  arresting  hem- 
orrhage, for  the  division  and  trim- 
ming  of   the   soft   parts  and   the 
bone,  and  those  for   uniting   and 
dressing  the  wound.     The  prepa- 
ration of  the  surgeon  (page  113  et 
seq.)  and  patient  for  the  operation, 
the  agents  for  controlling  and  ar- 
resting hemorrhage   (page   65   et 
seq.),    together    with    the    various 
methods    of    securing    and   main- 
taining the  coaptation  of  the  cut 
surfaces  (page  96  et  seq.),  drain- 
age, and  various  forms  of  dressing, 
antiseptic  and  otherwise,  have  been 
heretofore    considered,   therefore, 
tlicre    remain   to    be    enumerated 
under  this  heading  only  those  in- 
struments   especially    adapted    to 
the   requirements   of   amputation. 
The  instruments  (Fig.  486)  are  amputating  knives,  scalpels   saws,  lion- 
jaw  forceps,  periosteal  elevator,  special  metal  retractor,  tenaculum,  and  a 

support  for  the  stump.  . 

The  Amputating  Knives  (Fig.  187).-The  modern  amputating  knives 
can  be  used  for  making  circular  flaps,  or  for  transfixion.     Some  are  single- 


bed 
Fig.  487.— Amputating  knives. 


462 


OPERATIVE  SURGERY. 


edged,  others  may  be  double-edged  (a,  h)  entirely  (Catliu),  or  only  for  an 
inch  or  two  from  the  point.  The  length  of  the  knife  selected  will  depend 
upon  the  size  of  the  limb  to  be  operated  upon,  and  should  be  about  one 
and  a  half  times  the  diameter  of  the  limb.  While  it  may  be  inconsistent 
with  good  taste,  it  is  entirely  consistent  with  good 
judgment  and  economy  to  amputate  an  arm  or  fore- 
arm with  the  knife  intended  for  use  at  the  thigh, 
and  the  result  will  be  equally  satisfactory.  On  the 
other  hand,  the  absence  of  the  stereotyped  amputation 
knife  constitutes  no  good  reason  for  the  deferment  of 
operation  in  the  presence  of  the  wisdom  of  prompt 
action  and  the  possession  of  one  or  more  scalpels. 

The  ma7iner  of  grasping  the  amputating  knife, 
prior  to  and  during  the  division  of  the  soft  parts, 
may  add  much  to  the  general  effect  of  the  procedure 
and  to  the  comfort  of  the  operator.  The  knife  should 
be  grasped  lightly  at  first  with  the  edge  looking  for- 
ward, near  enough  to  the  extremity  of  the  shank  to 
permit  the  upper  end  of  the  handle  to  play  between 
the  heads  of  the  metacarpal  bones  of  the  thumb  and 
index  finger  when  swung  backward  and  forward  (Fig. 
488).  Two  methods  are  employed  of  carrying  the 
knife  entirely  around  the  limb :  1.  Stand  with  the  left 
side  toward  the  patient,  seize  the  limb  above  the  point 
of  intended  operation  with  the  left  hand,  an  assistant  holding  its  distal 
extremity;  place  the  left  foot  forward,  slightly  bend  the  right  knee,  and 
with  the  knife  held  by  the  right  hand,  as  before  described  (Fig.   489), 


Fig.  488. — How  to  grasp 

amputating  knife. 


Pig.  489. — How  to  carry  knife  around  limb. 


stoop  downward  and  forward  sufficiently  to  carry  first  the  knife  and  fore- 
arm under,  and  then  the  knife  over  the  limb,  placing  its  heel  as  near  to 
the  upper  surface  of  the  limb  as  is  convenient,  when,  with  a  sawing  motion, 
the  knife  is  drawn  toward  the  operator  beneath  the  limb,  then  upward 


AMPUTATIONS. 


463 


between  it  and  the  operator,  and  so  on  around  until  it  joins  the  begin- 
ning of  the  cut,  making  a  complete  circular  division.  If  the  knife  be 
properly  grasped,  the  handle  will  pass  readily  between  the  thumb  and 
forefinger  as  the  hand  passes  around  the  limb,  enabling  the  surgeon  to 

ease,  and  without  the  least  man- 
make  the  section  with  perfect 
ifestation  of  stiffness.  2.  The 
method  may  be  reversed  by 
first  passing  the  hand  and  knife 
over  instead  of  under  the  liml) 
(Fig.  490) ;  otherwise  the  ma- 
nipulations are  the  same.  The 
latter  plan,  however,  is  less  nat- 
ural, besides  which  it  exposes  the 
arm  of  the  operator,  and  the 
integument  to  be  divided  last, 
to  the  flow  of  blood.  If  the 
handle  of  the  knife  be  grasped 
fi^rmly  between  the  thumb  and 
two  fingers,  and  carried  around 
the  limb  with  a  deliberate  long 
sawing  motion,  accompanied 
with  firm  application  of  the  edge 
to  the  tissue,  the  cutting  depth 
can  be  easily  regulated.  If  the 
operator  be  not  acquainted  with 
the  technique  of  this  method  he 
can  soon  familiarize  himself  with  it  by  passing  the  knife  around  the  limb  as 
described  with  the  bach  of  the  blade  against  the  surface.  The  method  com- 
monly employed  and  figured  in  text-books  (Fig.  491)  is  stiff  and  awkward 
at  the  outset,  and  as  the  knife  advances 
in  its  course  the  operator's  posture  and 
expression  become  both  unnatural  and 
labored. 

The  Catlin  (Fig.  487,  a,  5). —The 
Catlin  is  employed  chiefly  to  divide  the 
tissues  in  the  interosseous  space  in  am- 
putations of  the  leg  and  forearm.  It  can 
be  readily  supplanted  for  this  purpose 
by  the  single-edged  narrow  knife,  pro- 
vided the  latter  be  withdrawn  to  com- 
plete the  division  of  the  interosseous 
tissues  instead  of  changing  the  direc- 
tion of  the  cutting  edge  while  the  blade  yet  remains  between  the  bones. 
The  latter  act  will  bruise  and  tear  the  interosseous  tissues. 

The  Scalpels. — Two  or  three  ordinary  scalpels  should  be  at  hand  for  use 
in  separating  the  flaps  (Fig.  486,  a). 


Fig.  490. — Another  method. 


Fig.  491. — A  common  method. 


464: 


OPERATIVE  SURGERY. 


A  knife  witli  a  long  narrow  blade  is  the  better  for  amputating  at  the 
phalangeal  articulations. 

The  Saws. — The  ordinary  broad-bladed  saw  (Fig.  492)  and  the  bow- 
backed (Fig.  493)  are  in  common  use.     The  first  meets  all  requirements 


Fig.  493. — Broad-bladed  saw. 

except  in  certain  excisions,  when  either  the  chain  saw  (Fig.  376)  or  Butcher's 
saw  (Fig.  494)  must  be  employed.  The  Gigli-Haertel,  and  the  narrow,  lift- 
ing-back saws  (Fig.  486,  k),  are  of  use  in  severing  small  bones  and  spiculse. 


•PW-^-^M'J'VM'M'J'M'VW'I't'l'VV-r'VI'l- 


Fig.  493. — Common  bone  saw. 

TliG  proper  method  of  using  a  saiv  should  be  given  some  attention  (Fig. 
495).  After  the  division  of  the  soft  ]3arts  the  surgeon  grasps  the  saw  firmly, 
places  its  heel  on  the  bone  close  to  the  border  of  the  retracted  muscles  in  a 


Fig.  494.— Butcher's  bone  saw. 


line  made  through  the  periosteum  by  the  knife,  and,  while  guided  by  the 
thumb  nail  applied  at  the  saw-point,  slowly  and  carefully  draws  it  backward 
along  the  first  four  or  five  inches  of  its  edge,  then  raises  it  from  the  track, 
and  places  it  as  before,  repeating  the  operation  until  a  track  of  sufficient 


AMPUTATIONS. 


465 


depth  is  made  to  retain  the  saw  in  place  during  to-and-fro  movements; 
these  should  be  made  by  quick,  sharp,  but  not  rapid  strokes,  until  the  bone 
is  nearly  severed,  when  care  must  be  taken,  or  the  saw  will  be  clamped  and 
the  remaining  portion  of  bone  broken  off.     If  the  handle  of    the  saw  be 

raised  and  the  remaining  portion  be  divided 
at  a  different  angle  with  the  bone,  the 
danger  of  the  breaking  is  lessened.  When 
two  bones  are  to  be  sawed  off,  the  saw 
should  be  started  in  the  less"  movable  bone 
and  then  turned  so  as  to  include  both  for 
a  time,  when  either  may  be  sawed  inde- 
pendently of  the  other.  If  the  movable 
bone  clamp  the  saw,  cut  off  the  solid  one 


Fig.  495. — Sawing  the  bone. 


Fig.  496. — Retractor  for  two  bones. 


first;  this  course  gives  better  final  command  of  the  movable  bone.  The 
proximal  and  distal  portions  of  the  limb  should  be  firmly  supported  during 
the  division  of  the  bone,  care  being  taken  not  to  hold  the  limb  in  such  a 
manner  as  to  clamp  the  instrument  during  the  final  act  of  the  sawing. 

The  Bone  Forceps. — Listen's  cutting  forceps  are  used  for  trimming  off 
rough  bony  prominences.  Fergusson's  lion-jawed  and  Farabcuf's  forceps 
(Figs.  375  and  378)  are  excellent  instruments  for  grasping  the  bone  to 
steady  the  part,  and  are  also  used  for  removing  bone  by  twisting,  when  great 
force  is  required. 

The  Periosteal  Elevator  and  Rugine  (Fig.  486,  e,  i). — Although  these 
instruments  are  convenient  for  the  purpose  of  raising  periosteum  for  flaps, 
yet  they  are  not  necessary,  as  the  same  can  be  accomplished  with  the  end 
of  the  metal  handle  of  a  scalpel. 


Am 


OPERATIVE  SURGERY. 


The  Cloth  Retractor. — The  cloth  retractor  is  made  of  linen  or  ordinary 
muslin,  fashioned,  by  tearing,  according  to  the  size  and  anatomical  arrange- 
ment of  the  limb  to  which  it  is  applied.  If  for  two  bones,  one  extremity  of 
the  retractor  should  be  torn  into  three  strips  (Fig.  496),  the  middle  one  for 
use  between  the  bones  (Fig.  497),  the  remaining  ones 
to  be  carried  around  them.  If  but  one  bone  be  pres- 
ent the  retractor  is  torn  partially  through  the  mid- 
dle (Fig.  498),  and  applied  as  shown  in  Fig.  499. 


Fig.  497. — Three-tailed  retractor  applied. 


Fig.  498.— Retractor  for 
one  bone. 


A  special  metal  retractor,  devised  for  use  at  the  thigh  and  arm,  is 
worthy  of  employment.  It  consists  of  two  thin  slotted  plates  of  metal 
so  fashioned  that  they  will  simultaneously  grasp  the  bone   and  retract 


the  flaps  when  properly 
joined  and  firmly  held  by 
the  rings  (Fig.  500).  After 
the  soft  parts  are  divided 
down  to  the  bone,  the  bone 
is  grasped  at  that  point  by 
the  opposing  slots  of  the 
respective  plates,  which  are 
then  drawn  upward  by  the 
rings  against  the  muscular 
tissue  (Fig.  501).  This  re- 
tractor protects  the  muscles 
during  division  of  the  bone, 
is  an  admirable  guide  for  the 
saw,  and  enables  the  assist- 
ant to  firmly  hold  the  proxi- 
mal portion  of  the  limb  while 
the  bone  is  being  severed. 


////, 


— i4jf=^' 


Fig.  499. — Two-tailed  retractor  applied. 


AMPUTATIONS. 


467 


]Mctal  retractor,  open. 


A  tenaculum  should  be  at  hand  for  the  purpose  of  picking  up  small 

bleeding  points  of  severed  vessels  for  the  purpose  of  ligature  when  necessary. 

The  Aneurismal  Needle  (Figs.  175,  177,  and  178). — Not  infrequently 

this  implement  is  needed  to  aid  the  surgeon  in  tying  collateral  branches 

which  arise  so  close  to 
the  ligature  as  to  im- 
peril the  formation  of 
a  proper  clot.  In  dis- 
eased vessels  this  pre- 
caution is  of  greater 
significance  than  in 
healthy. 

A  support  for  the 
stump  composed  of 
wood,  or  pads  of  special  device,  or  an  ordinary  pillow,  should  be  provided 
and  confined  to  the  limb  with  rollers.  This  support  steadies  the  limb  and 
at  the  same  time  affords  a  ready  means  of  handling  the  stump.  In  lieu  of 
this  the  limb  may  be  swung  from  a  cradle  by  elastic  or  inelastic  suspension, 
which,  although  it  adds  to  ease  of  movement  and  comfort,  does  not  always 
control  properly  muscular  contraction. 

The  Cornments. — Before  beginning  an  amputation  the  operator  should 
rehearse,  in  his  mind  at  least,  the  entire  operation,  as  he  contemplates 
it;  by  doing  this  he  will  be  quite  certain  to  anticipate  the  details  and 
complications  of  the  procedure.  The  surgeon  should  plan  his  work  with 
careful  precision,  even  to  marking  out  on  the  limb  the  outlines  of  the  flaps, 
and  such  other  incisions  as  may  be  required.  We  are  aware  that  this  is  sel- 
dom practiced,  even  by  the  most  experienced  surgeons ;  but,  within  our  own 
observation,  had  it  been  done  better  results  might  have  been  secured.  The 
young  surgeon,  too,  often  fancies  that  to  do  this  proclaims  himself  as  igno- 
rant and  inexperienced  ;  such,  however,  is  not  always  the  case ;  it  rather 
serves  to  emphasize  his  cautious  and  painstaking  qualities.  An  amputa- 
tion should  be  done  without  haste,  when  the  safety  of  the  patient  will  per- 
mit, remembering  that  it  is  done  quickly  when  it  is  done  well. 

The  operator  should  stand  in 
such  relation  to  the  patient  that 
the  left  hand  can  readily  con- 
trol any  undue  haemorrhage  by 
compression  or  otherwise. 

The  primary  incision  should 
be  located,  if  possible,  so  that 
the  escaping  blood  will  not  ob- 
scure the  course  of  the  incisions 
subsequently  made. 

The  division  of  important  vessels  should  be  made  last,  when  possible. 
The   tissues  should  not  be  retracted   until  after  complete  division,  if 
practicable. 

In  flaps  made  by  transfixion  the  tissues  constituting  them  are  raised  or 


Fig.  501. — INletal  retractor,  closed. 


468  OPERATIVE   SURGERY. 

depressed,  according  to  the  aspect  of  the  limh  from  which  the  flaps  are 
made.    Those  in  front  of  the  bone  are  raised,  those  behind  depressed. 

After  the  limb  is  removed,  the  open  mouths  of  the  vessel  should  be 
caught  by  forcipressure,  forceps,  etc.,  after  which  the  control  of  the  circu- 


FiG.  502. — Catching  and  tying  bleeding  points. 

lation  is  slowly  relaxed,  and  all  bl'eeding  points  arrested  as  they  appear  by 
suitable  means  (Fig.  503).  The  surgeon  can  then  proceed  deliberately  to 
ligature  the  vessels  thus  secured.  The  open  ends  of  tendinous  sheaths 
should  he  closed  hy  suturing  to  exclude  infection. 

AMPUTATIONS    AT    UPPER   EXTREMITY. 

The  General  Remarhs. — In  amputations  at  the  carpus  and  digits  it  is 
important  to  remember  that  usefulness  and  symmetry  are  the  ends  to  be 
attained.  If  strength  and  usefulness  be  the  desiderata,  the  insertions  of  the 
muscles  and  ligaments  that  endow  the  part  with  important  functions  should 
be  preserved  (Fig.  503). 

It  is  therefore  imperative  that  the  surgeon  carefully  study  the  func- 
tions of  the  important  muscles  associated  with  the  hand,  and  preserve  if 
possible  their  points  of  insertion.  The  surface  markings  of  the  palm  and 
of  the  digits  (Fig.  504)  and  the  relation  of  the  web  of  the  fingers  to  the  heads 
of  the  metacarpal  bones  and  to  the  vessels  are  important.  It  is  a  well-estab- 
lished principle  that  every  portion  of  the  hand  of  a  laboring  man  which  pos- 
sesses motion  and  can  become  of  service  to  him  should  be  saved.  In  the 
case  of  one  whose  circumstances  or  vocation  will  permit,  the  sacrifice  of  use- 
fulness to  symmetry  may,  with  the  concurrence  of  the  patient,  be  made. 


AMPUTATIONS. 


469 


Amputation  at  the  Phalangeal  Articulations  (Disarticulation).  The 
Anatoiiiicdl  Fuinis.—Tlio  iin^i  row  of  surgical  phalanges  is  flexed  by  the  ter- 
minal insertions  of  the  flexor  profundus  digitorum ;  the  second,  by  those  of 
the  flexor  sublimis  digitorum ;  the  third,  l)y  the  flexor  sublimis,  through  the 
vincula  accessoria  tendinum,  by  dense  fibrous  bands  connecting  the  tendons 
of  the  flexor  sublimis  with  the  distal  extremity  of  that  row  (Fig.  505),  also 
by  the  secondary  action  of  the  lumbrical  muscles  and  interosscii  on  the  ex- 
tremities of  the  bones  of  this  row. 

TJie  terminal  phalanx  is  amputated  by  seizing  and  flexing  it  to  a  right 
angle  with  the  second  (Fig.  506) ;  an  incision  which  opens  the  joint  is  then 
made  on  its  dorsal  surface,  on  a  line  corresponding  to  the  transverse  diam- 
eter of  the  second  phalanx.  Divide  the 
lateral  ligaments  with  the  point  of  the 
knife;  separate  the  articular  surfaces, 
and  pass  the  blade  between  them;  cut 
along  the  under  surface  of  the  pha- 
lanx to  be  removed,  close  to  the  bone 


Fig.  503. — Conservatism  illustrated.  Thumb, 
stump  of  index  finger,  and  the  little  finger 
remaining. 


Fig.  504. — Surface  markings  of  the  palm 
of  the  hand. 


(Fig.  507),  far  enough  to  make  a  palmar  flap  of  sufficient  length  to  easily 
cover  the  end  of  the  stump  (Fig.  508).  The  application  of  the  rule  previ- 
ously given  regarding  the  length  of  flaps  will  enable  the  operator  to  meet 
this  requirement.  If  the  base  of  the  flap  be  first  formed  by  dividing  the  tis- 
sues at  each  side  of  the  phalanx,  for  three  or  four  lines  down  to  the  bone, 
the  knife  will  then  hug  the  under  surface  of  the  bone  in  making  the  flap 
without  cutting  the  base  of  the  flap  too  narrow,  which  otherwise  would  oc- 
cur on  account  of  the  proximal  extremities  of  the  phalanges  being  thicker 


470 


OPERATIVE  SURGERY. 


than  their  bodies.  Eemove  the  flexor  tendon  from  the  flap,  tie  the  vessels, 
close  the  open  end  of  the  tendinous  sheath  with  a  suture,  confine  the  flap  in 
position  with  two  or  three  fine  sutures,  and  dress  antiseptically. 

The  amputations  at  the  second  row  can  be  performed  in  precisely  the 
same  manner  as  the  first;  or,  with  the  finger  extended,  transfix  the  soft 

a 


Fig.  505. — Attachments  of  tendons  to  phalanges,  a.  Extensor  communis  digitorum.  h. 
First  surgical  phalanx,  c.  Fibrous  bands  between  common  flexor  tendons  and  distal 
extremity  of  the  third  surgical  phalanx,  d.  Tendons  or  flexor  sublimis  digitorum. 
e.  Tendon  of  flexor  profundus  digitorum.  /.  Vineula  accessoria  tendinum.  g.  Head 
of  metacarpal  bone.  h.  Joint  between  second  and  third  surgical  phalanges,  i.  Joint 
between  first  and  second  surgical  phalanges. 

parts  on  the  palmar  surface  opposite  the  joint,  and  cut  downward  until  a 
well-rounded  flap  of  proper  length  is  formed  (Fig.  509).  Then  carry  the 
knife  upward  between  the  articular  surfaces  and  through  the  soft  parts  on 
the  dorsum.  The  transfixion  method  is  objectionable,  because  the  vessels 
may  be  split  or  the  flap  be  imperfectly  formed  (Fig.  510). 

The  Remarhs. — Either  of  the  phalanges  may  be  amputated  at  the  center 
by  a  short  dorsal  and  a  long  palmar  flap.    If  a  third  surgical  (flrst  anatomi- 


FiG.  506.— Flexed  phalanx.  Pig.  507.— Making 


Fig.  508. — Flap  completed. 


cal)  phalanx  be  amputated  at  the  center,  the  power  of  flexion  is  limited  to 
the  lumbrical  and  interosseii  muscles  and  the  vincular  tendons  connecting  the 
base  of  the  phalanx  with  the  flexor  sublimis  digitorum.  These  connections 
can  be  supplemented  wisely  by  stitching  the  divided  tendons  to  the  contigu- 


AMPUTATIONS.  471 

oiis  theca.  Tlie  division  at  this  situation  is  regarded  by  many  as  objection- 
able practice,  disarticulation  being  preferable.  These  anatouiical  facts  have 
led  the  writer  to  amputate  frequently  in  the  continuity  of  this  phalanx,  and 
always  with  entirely  satisfactory  results.  If  symmetry  be  a  primary  considera- 
tion, this  method  of  amputation  can  not  be  commended.  In  the  case  of  the 
thumb,  the  index  and  little  fingers,  whatever  adds  usefully  to  the  length  of 
the  digits  should  be  saved,  as  the  range  of  motion  of  the  thumb  and  little 
finger  is  more  extensive  than  that  of  the  others,  and  the  presence  of  the 
index  finger  or  its  stump  greatly  aids  a  crippled  thumb  in  the  performance 
of  its  functions.  However,  it  should  not  be  forgotten  that  it  is  not  wise 
to  make  unnecessary  sacrifice  of  a  portion  of  any  phalanx,  as  this  portion 
may  be  of  great  prehensile  service  in  conjunction  with  a  crippled  thumb — 
at  all  events  of  more  use  than  the  most  ingenious  artificial  device.  The 
phalanges  are  amputated  frequently  by  flaps  fashioned  according  to  the 
demands  of  the  case.  Unequal  flaps  at  both  surfaces  of  the  finger,  and 
those  of  single  or  lateral  pattern,  can  be  employed  when  required.  It  is 
better  at  all  times  to  subordinate  symmetry  to  the  attainment  of  pre- 
hensile advantage.     It  is  better  that  transfixion  in  making  flaps  from  the 

digits   be  not   practiced,  be- 
A  /  cause  when  thus  made  they 

I  •  I  are   often   ill  fashioned   and 

C       ^     7" — C        — ?'z3s|i=s=i==^====s~--     Diay  contain  tendinous  tissue. 

^--..,^  V^^^     I  ^--^..^^^    v^^:iM-|       The  Gigli-Haertel  saw  is  the 

^'^^^"--tT— ____  ~-.-_IIi^«^^_     ijest   agent   for  dividing  the 

I  bone ;    bone-cutting    forceps 

a  i  often  crush  and  s]3linter  it. 

_  The  free  communication    of 

Fig.  509. — Flap  by  Fig.  510.— Opening  ioint.    ,i  •  i  j.      j-  , 

transfixion!  r       &  j  ^|-,q  synovial  tendinous  struc- 

tures of  the  little  finger  and 
the  thumb  with  those  of  the  carpus  (Fig.  369)  explains  the  occasional  ex- 
tensive inflammation  which  follows  injury  of  these  digits.  It  suggests  also 
closing  their  open  ends  with  a  suture,  or  by  sewing  the  divided  tendons 
to  them.  The  open  ends  of  the  sheaths  of  the  remaining  tendons  should  be 
treated  in  like  manner,  although  they  terminate  in  blind,  noncommuni- 
cating  extremities  at  the  lower  part  of  the  palm. 

Amputation  at  the  Metacarpo-phalangeal  Articnlations. — It  is  recom- 
mended by  some  that  this  operation  be  practiced  in  lieu  of  amj)utation  at 
the  middle  of  the  third  phalanges  (surgical)  of  the  second  and.  third  fingers, 
or  even  disarticulation  between  the  second  and  third  phalanges. 

We  are  satisfied,  however,  that  the  hand  will  be  far  stronger  if  the  stump 
be  allowed  to  remain,  since  it  is  soon  easily  flexed  and  extended,  and  the 
continuance  of  these  motions  serves  to  stimulate  and  nourish  the  common 
muscles  engaged  in  performing  them,  and  thereby  strengthens  the  power  of 
the  remaining  fingers. 

Amputation  of  the  Second  or  Third  Fingers. — Amputation  of  these 
fingers  at  the  metacarpo-phalangeal  articulation  is  done  by  the  oval-flap 
method,  and  the  flap  should  be  marked  out  before  the  operation  is  com- 


472 


OPERATIVE  SURGERY. 


menced  (Fig.  511).  The  flaps  must  be  taken  from  the  finger  to  be  removed, 
and  should  be  of  generous  dimensions.  The  limit  of  the  incision  above  cor- 
responds to  the  head  of  the 
metacarpal  bone,  the  lower 
limit  to  the  transverse  line 
of  the  palm  joining  the 
fingers  to  the  web.  Sepa- 
rating widely  the  contigu- 
ous fingers,  seize  the  con- 
demned finger,  extend  it 
well,  and  carry  the  incision 
transversely  along  the  line 
beneath,  then  in  a  curved 
direction  upward  along  the 
side  of  the  finger  to  the 
head  of  the  metacarpal 
bone.  This  incision  is  re- 
peated on  the  opposite  side, 
the  tissue  carefully  divided, 
and  the  finger  removed 
(Fig.  513).  The  trans- 
verse palmar  incision  can 
be  made  (Fig.  514,  c),  and 
many  prefer  that  variation. 
Better  drainage  will  be  se- 
cured if  the  flap  be  reversed 
by  forming  its  retiring  an- 
gle on  the  palmar  instead 
of  the  dorsal  surface  of  the 
hand  (Figs.  513  and  514). 

The  Lateral-flap  Operation. — The  lateral-flap  operation  is  best  adapted 
to  the  thumb,  index,  and  little  fingers  (Fig.  513) ;  it  can,  however,  be  em- 
ployed at  the  ring  and  middle  fingers.  The  limit 
of  the  dorsal  incision  is  the  same  as  in  the  pre- 
ceding. The  lower  limit,  after  crossing  the  trans- 
verse line  of  the  web,  extends  toward  the  palm 
about  a  third  of  an  inch.  The  flaps  are  taken 
from  the  sides  of  the  finger  to  be  removed. 

In  the  case  of  the  middle  and  ring  fingers  the 
flaps  should  be  equilateral  (Fig.  514,  d).  For  the 
thumb,  index,  and  little  flnger,  that  portion  of  each 
digit  against  which  pressure  is  most  constantly 
brought  should  be  covered  by  the  longer  flap, 
which  is  taken  respectively  from  the  outer  surface 
of  the  index  finger,  the  inner  surface  of  the  little 
finger,  and  from  the  palmar  aspect  of  the  thumb,  the  base  of  the  flap  being 
on  a  level  with  the  joint  (Fig.  514,  a,  b,  e).    The  longer  one  is  dissected  off. 


Fig.  511. — Amputating  second  finger,  oval  flap. 


Fig.  513. — Finger  removed. 


AMPUTATIONS. 


473 


after  %vlucli  the  smaller  one  is  made.    Divide  the  ligaments  and  tendons  and 
remove  the  digit. 


O 


Fig.    513. — Appearance  of  flap 
at  palmar  surface. 


Fig.  514. — Flaps  in  disarticulation  of  fingers,  a. 
Long  palmar  flap.  6.  Long  external  flap.  c. 
Circular  method,  dorsal  incision,  d.  Lateral 
flaps,    e.  Long  outer  flap. 


Amputation  of  the  Thumb,  Little,  and  Index  Fingers  at  the  Carpo-meta- 
carpal  Articulation.  The  Oval  Method. — The  oval  method  can  he  employed 
eqiiall}'  well  with  the  thumh,  index,  and  little  fingers.  The  limit  of  the 
dorsal  incision  in  either  instance  is  the  proximal  extremity  of  the  metacarpal 


Fig.  515.— Oval  method. 


Fig.  516. — Opening 
the  joint. 


Fig.  517. — Wound  united, 
linear  cicatrix. 


hone  to  he  removed.     The  upper  or  ])almar  limit  is  the  transverse  line  at 
the  junction  of  the  finger  with  the  palm.     On  removing  the  thumh  by  this 
33 


474 


OPERATIVE  SURGERY. 


method  begin  the  first  incision  at  the  base  of  the  metacarpal  bone  of  the 
thumb  (Fig.  515),  carrying  it  along  in  a  slightly  curved  direction  to  the 

outer  side  of  the  metacarpo-phalangeal  articu- 
lation, then  inward  through  the  line  of  the  web. 
The  second  one  joins  the  first  near  the  base 
of  the  metacarpal   bone,   and   takes    a   corre- 


FiG.  518. — Lateral-flap  method. 


Fig.  519. — Making  outer  flap. 


spending  course  along  the  inner  side,  meeting  the  former  at  the  inner 
extremity  of  the  transverse  line  of  the  web.     The  flaps  are  dissected  off. 


Fig.  520.— Amputation  through  fourth 
and  fifth  metacarpal  bones. . 


Fig.  531. — Amputation  through  one  meta- 
carpal bone. 


and  the  articulation  between  the  metacarpal  bone  and  the  trapezium  is 
opened  from  the  ulnar  side,  to  avoid  injuring  contiguous  joints  (Fig.  516). 
The  union  of  the  flaps  leaves  a  linear  cicatrix  (Fig.  517). 


AMPUTATIONS. 


475 


The  Lateral-flap  Method  (Fig.  518). — The  lateral-flap  method  can  he 
more  quickly  and  easily  performed  than  the  former,  hut  leaves  the  cicatrix 
in  a  less  advantageous  situation.  Abduct  the  thumb  and  enter  the  knife 
between  the  first  and  second  metacarpal  bones,  carry  it  up  betvreen  them 
with  a  sawing  motion,  till  the  head  of  the  first  is  reached.  Cautiously  dis- 
articulate the  digit  from  within  outward,  increase  the  abduction,  and  carry 
the  blade  through  the  joint  and  along  the  outer  side  of  the  metacarpal  bone, 
thus  making  the  outer  flap,  which  should  terminate  opposite  the  web  of  the 
thumb  (Fig.  519). 

Amputation  through  the  Metacarpal  Bones. — In  amputation  through 
two  or  more  of  these  bones  the  principal  flap  should  be  taken  from  the  pal- 
mar surface,  although  it  may  be  taken  from  the  border  of  the  hand  and 
palm  as  well  (Fig.  530).  If  but  one  metacarpal  bone  be  attacked,  the  inci- 
sions are  the  same  as  those  for  amputation  at  the  metacarpo-phalangeal 
articulation  by  the  oval  method,  the  only  difference 
being  that  their  upper  limit  will  correspond  to  the 
point  of  proposed  section  of  the  bone  (Fig.  521). 
The  bone  is  exposed  by  reflection  of  the  soft  parts 
up  to  the  point  of  proposed  division,  after  which  it 
is  sawed  through  with  -a  chain,  Gigli-Haertel,  or 
metacarpal  saw,  separated  carefully  from  its  palmar 
connections,  and  removed  with  the  finger  attached. 
If  a  saw  be  not  convenient,  the  bone-cutting  forceps 
(Listen)  can  be  used,  although  with  some  risk  of 
splintering  the  bone.  This  operation  is  often  per- 
formed in  preference  to  disarticulation  at  its  head, 
in  order  to  give  symmetry  to  the  hand  (Fig.  522). 

The  BemarJcs. — The  division  of  the  transverse 
ligament,  which  extends  between  the  heads  of  the 
Fig.  522.— Appearance  of   metacarpal  bones,  lessens  the  strength  of  the  grip, 
hand  after  amputation   This  operation  is  therefore  not  to  be  recommended 
carpafboni!''"^   "''*''"   except  in  those  of  sedentary  habits,   and  even  in 
these  instances  the  subsequent  atrophy  of  the  soft 
parts  and  the  separation  of  the  metacarpal  bones  at  the  seat  of  the  oper- 
ation do  much  to  lessen  the  cosmetic  effect  originally  gained  by  the  am- 
putation.    If  possible,  the  divided  ends  of  the  palmar  transverse  ligament 
should  be  sewed  together,  which  will  serve  to  lessen  the  tendency  to  the 
latter  element  of  deformity. 

Amputation  of  the  Last  Four  Metacarpal  Bones  (Disarticulation). — 
Make  a  semilunar  flap  from  the  tissue  of  the  palm  by  a  curved  incision, 
beginning  at  the  web  of  the  thumb  and  terminating  at  the  ulnar  border  of 
the  flfth  metacarpal  bone  (Fig.  523).  This  flap  can  be  made  by  transfixion  if 
desired  (Fig.  524).  The  dorsal  incision  (Fig.  525)  begins  at  the  same  point 
of  the  web  of  the  thumb,  and  is  carried  to  the  upper  third  of  the  metacarpal 
bone  of  the  index  finger,  and  from  there  transversely  across  until  it  meets 
the  ulnar  extremity  of  the  first  incision.  The  flaps  are  reflected  up  to  the 
carpo-metacarpal  joints,  the  hand  is  strongly  abducted,  and  the  carpo-meta- 


476 


OPERATIVE  SURGERY. 


carpal  joint  opened  from  the  ulnar  side,  using  great  caution  not  to  injure 
the  articulation  of  the  trapezium  and  the  metacarpal  Ijone  of  the  thumh. 
Without  the  thumb  this  operation  would  be  of  little  avail  in  securing  a  use- 


FiG.  523. — Line  of  palmar 
incision. 


Fig.  o24. — Making  by  trans- 
fixion. 


Fig,  525. — Line  of  dorsal 
incision. 


ful  stump.     Unite  the  flaps  with  interrupted  sutures,  introduce  at  either 
angle  of  the  wound  drainage  when  needed  (Fig.  520),  and  treat  antiseptically. 

Amputation  of  the  Inner  Three  Metacarpal  Bones. — Begin  the  palmar 
incision  at  a  little  distance  Ijelow  the  base  of  the  fifth  metacarpal  bone,  carry 
it  downward  and  outward  across  the  palm  below  and  parallel  with  the 
transverse  palmar  fissure  for  about  an  inch  and  a  half,  then  toward  the  base 
of  the  middle  finger,  finally  dividing  the  web  of  the  hand 
at  the  outer  side  of  that  digit.  A  like  flap  is  then  made 
on  the  dorsal  surface,  the  bones  are  removed,  and  the 
flaps  united  and  dressed  in  the  usual  manner. 

The  principles  embodied  in  the  last  two  amputations 
are  applicalde  to  amputation  of  the  metacarpal  bones  of 
the  last  two  fingers. 

Amputation  of  the  Four  Metacarpal  Bones  with  the 
Fingers  requires  a  long  convex  palmar  flap  and  a  short 
concave  dorsal  one.  The  bases  of  the  metacarpal  bones 
are  saved  as  they  afford  attachment  to  important  flexors 
and  extensors  of  the  carpus. 

The  Remarhs. — Amputation  of  the  fingers  and  of  the 
metacarpal  bones  exposes  the  synovial  sacs  of  the  carpal 
bones  and  tendons  (Fig.  413)  to  the  dangers  of  inflamma- 
tion. It  is  fortunate  for  this  reason  that  these  sacs  are 
not  common  to  their  respective  tissues.  The  relations  of 
the  surface  markings  of  the  palm  (Fig.  504)  to  the  bones  and  vessels  of  the 
carpus  are  of  much  significance  in  amputation  and  excision. 

After-treatment.— The  wounds  of  these  amputations  should  be  closed 
with  silkworm  gut  or  horsehair,  and  simple  drainage  should  be  employed 


Fig.  526.— Appear- 
ance of  stump. 


AMPUTATIONS. 


477 


for  the  first  two  or  three  days.  If  the  tissues  have  been  bruised  or  lacerated, 
freer  drainage  is  advisable.  The  hand  should  be  kept  in  an  elevated  posi- 
tion, and  the  wrist  joint  confined  with  a  splint. 

The  results  of  amputations  of  the  thumb  and  fingers  are  favorable.  Only 
three  to  six  per  cent,  and  even  less,  with  antiseptic  precautions,  die. 

Amputation  at  the  Wrist.  (Disarticulation.) — The  bones  entering  directly 
into  this  articulation  are  the  radius,  scaphoid,  and  semilunar. 

The  Anatomical  Points. — The  location  of  the  joint  can  be  determined, 
1,  by  forcibly  bending  the  carpus  backward,  when  the  angle  on  the  dorsal 
surface  formed  by  the  hand  and  forearm  indicates  the  radio-carpal  joint ;  2, 
by  drawing  a  line  transversely  from  one  styloid  process  to  the  other  the  joint 
is  about  one  fourth  of  an  inch  above  this  line.  The  tip  of  the  styloid  process 
of  the  ulna  is  nearly  opposite  the  joint  at  that  situation.  The  lowest  trans- 
verse fold  of  skin  on  the  anterior  surface  of  the  wrist  is  about  three  fourths 
of  an  inch  below  the  joint ;  this  fold  indicates  the  upper  border  of  the  annu- 
lar ligament.  The  integument  on  the  back  of  the  wrist  is  thinner  or  more 
lax  than  is  that  on  the  front,  therefore  it  retracts  more  than  does  the  latter 
— a  fact  to  be  considered  in  the  construction  of  flaps.  The  relations  of  the 
tendons,  bones,  and  synovial  sheaths  with  each  other  are  well  illustrated 
elsewhere  (Fig.  416).  Amputation  can  be  done  by  either  the  circular^  single 
palmar,  radial-flap,  or  the  douhle-flap  method. 

The  Circular-flap  Method. — To  establish  the  length  of  the  flap  ascertain 
one  fourth  of  the  circumference  of  the  wrist  at  the  articulation,  and  add 


Fig.  527. — Circular  method. 


Fig.  528. — Flaps  united. 


posteriorly  to  it  about  an  inch  to  compensate  for  the  retraction  which  char- 
acterizes the  integument  on  the  posterior  surface  of  the  carpus. 

Measure  downward  from  the  articulation  this  distance  and  divide  the 
soft  tissues  by  an  oblique  incision  which  becomes  circular  by  retraction; 
dissect  up  the  sleeve  of  integument  until  opposite  the  joint;  pronate  and 
forcibly  flex  the  carpus,  and  open  the  wrist  joint  on  the  dorsal  surface  by 


4Y8 


OPERATivio  ,siiiu;i':iiy. 


Ufi.  JnciHioii  (;xi(;ri(Jiri^  hciwccn  Uic  BiyloJd  proccHBo;-:;  divide  ilu;  iaicrui  iiga- 
mcnts,  pass  tho  blado  ttirough  the  articulation,  and  sever  the  remaining  struc- 
liirc;:  (\'"\ts.  r,;i7).  Join  ifx;  fiaf)H  in  tl)*;  long  axin  of  the  joint,  introduce  drain- 
ag':  and  nulurcK,  and  drcKH  antiHopticaJiy  (l''ig.  5?i8j,  it  for  any  reason  tiie 
flap  be  nijidc  loo  ;,fjorl,,  IJk!  defect  can  be  remedied 
by  Hawing  uH  <)\)\i<{\i<'\y  thf;  Htyloid  proecBses. 

y'kfi  Himjl,'',  I'almar  J'^lap. — ^riic  Hingie  palmar- 
flap  method  in  ca:  dy  p(3rformed,  and  makes  a  serv- 
iceable Btump.  Nlii.i-k  out  on  the  palmar  surface 
with  !i,  ntrong  H,(;alp<;l  a  Hemilunar  flap  about  three 
inclicr,  ;i.nd  ;i  linlf  irj  IcriMlli  going  down  t,o  IJic  flexor 
tcndoni;,  Ux:  hi),;*:  hiding  l(K;ated  just  bolow  tlie  apices 
of  l,ti(;  rJ.yloid  procci'.Keg  (Fig.  529);  reflect  it  up- 
Wiu'd  ;  dividi;  ilio  rcfnaining  tififiucs  in  front  of  the 
;i,rii(;ul;i.(,ion  ;  open  the  jiriicNlation,  paHK  tlio  knife 
throiigli  it,  ;uid  make  a  short  dorsal  lliif).  TIk; 
dorwil  (hip  can  ho  made  first,  the  joint  opejKMl  from 
h<;hind,  !i,nd  the  long  !i,fd,orior  llaj)  cut  from  the  joint  outward.  Thi-  fcjrmer 
in  the  heller  pl;in,  how<v<'r,  as  thus  a  more  symmetrical  flap  is  made. 

The.  JJouhla/lap  McJAod  (Ruysch). — Mark  out  the  distal  limits  of  the 
flaps  as  in  the  eircnlar  method;  flex  and  pronate  the  hand;  carry  a  semi- 
liimir  iruiiion  over  its  dorsum,  beginning  at  the  styloid  process  of  the  ulna, 
(jxtendin^'  lo  the  einiiibir  line  indicating  the  dorsal  extent  of  tlie  flap,  and 
terfrnnaiing  ;d,  IJie  ni,di;d   styloid  process  (Fig.  530).     Disscet   iijj   tlje  flap, 


Fi(i.  52'J. — Single  palmar 


-^ 


Fm.  580.— Making  (lorwil  flap. 


I'^KJ.  5151.-  Making  anU;rior  flap. 


a,l lowing  lint  (cndons  to  remain;  (lex  the  earpus  firmly,  atid  open  the  articu- 
bition,  iiK  in  I  hi'  eircular  method;  carry  the  blade  of  the  knife  through  the 
a,r(,ienhi,tion  (l''ig.  ^31)  arid  mal<c  the  anterior  flaj)  by  cutting  downward  and 
outward. 


AMPUTATIONS. 


479 


Fio.  582.— Dubrueil's 
method.    Radial  flap. 


The  Radial  Flap  (Dul^ruoil). — Make  a  flap  beginning  on  the  dorsal  sur- 
face at  a  point  just  above  the  articulation  and  at  the  junctioji  of  tbe  outer 
third  with  tlic  inner  two  thirds  of  that  surface,  and  extending  downward 
toward  the  thumb,  crossing  the  middle  of  the  metacarpal  bone  of  that  digit 
toward  the  palm,  then  curving  upward  and  inward  through  the  thenar  emi- 
nence and  terminating  at  a  point  on  the  palmar  surface  of  the  wrist  directly 
opposite  the  site  of  beginning  (Fig.  532).  Separate 
the  thuml)  flap,  connect  the  sides  of  its  base  by  an 
incision  carried  transversely  around  the  ulnar  side 
of  the  hand,  draw  the  skin  upward,  open  the  joint 
as  before,  remove  the  carpus,  and  properly  adjust 
tbe  flaps  (Fig.  533). 

The  Remarks. — The  pisiform  bone  is  frequently 
removed  from  the  flaps.  If  the  tissues  are  not 
impaired  by  diseased  or  acute  inflammatory  pro- 
cesses, the  sheaths  of  the  tendons  should  be  closed 
with  sutures,  even  including  the  ends  of  the  ten- 
dons, if  not  too  much  retracted,  after  which  the 
flaps  are  united,  suitable  drainage  provided,  anti- 
septic dressings  applied,  and  the  limb  placed  on  a 
retaining  palmar  splint  to  control  the  movements. 
If  the  tissues  be  infected,  the  wound  should  be 
packed  lightly  with  gauze,  dressed,  kept  clean,  and  when  granulations  ap- 
pear the  surfaces  should  be  united  in  a  suitable  manner. 

The  Results. — A  total  number  of  256  cases  of  amputation  at  wrist  joint 
done  for  various  causes  shows  the  following :  Of  189  cases  done  before  asep- 
sis, 26,31  per  cent  died.  Of  67  cases  done  under  asepsis,  1.8  per  cent  ter- 
minated fatally.    In  civil  practice  the  rate  is  less  than  12  per  cent. 

It  follows  therefore  that  amputation  at  the  wrist  joint  can  not  be  recom- 
mended on  the  ground  of  safety  to  the  patient.  There  are  other  objections 
of  less  importance,  which,  with  the  one  just  stated,  places  the 
operation  in  disfavor.  It  makes  a  stump  which,  owing  to 
the  feebleness  of  the  circulation  of  the  flaps,  often  becomes 
cold  and  even  chilblained,  and  the  bulbous  extremity  often 
interferes  with  the  application  of  the  properly  fitted  socket 
of  an  artificial  appliance.  However,  supination  and  prona- 
tion of  the  forearm  are  more  nearly  complete  than  in  am- 
putations of  the  forearm,  for  obvious  reasons. 

Amputation  of  the  Forearm. — The  forearm  can  be  am- 
putated l)y  either  of  the  following  methods :  TJie  circular  skin- 
flap,  the  eciuilateral  shin-flap,  or  the  antero-posterior  musculo-cutaneous  flap. 
The  Anatomical  Points. — The  insertions  of  the  supinator  muscles  should 
be  saved  when  possible,  to  preserve  their  function.  During  division  of  the 
interosseous  structures  the  forearm  should  be  supinated  to  afford  as  much 
room  as  possible  for  that  purpose. 

The  Circular  Shin-flap  Method. — Altliough  this  method  can  be  em- 
ployed at  all  parts  of  the  arm,  yet  it  is  best  suited  for  the  lower  third.    It 


Fig.  533.— Ap- 
pearance of 
stump. 


480  OPERATIVE   SURGERY. 

is  performed  by  first  carefull}^  laying  out  the  length  of  the  flap  equal  to  a 
little  more  than  one  fourth  the  circumference  of  the  limb  at  the  point  of 
bone  section.  Then  with  a  long  knife  divide  the  tissues  by  a  circular  inci- 
sion down  to  the  fascia  surrounding  the  muscles,  and  dissect  up  the  integu- 
mentary cuff  by  repeated  incisions  directed  toward  the  muscles  (Fig.  474). 

If  the  integumentary  cuff  be  too  small  to  be  turned  up  readily  it  is  slit 
up  at  the  most  dependent  part.  After  the  flap  is  reflected  sufficiently,  the 
muscles  are  divided  half  an  inch  or  so  below  the  line  of  its  refiection  by  a 
circular  sweep  of  the  knife  made  down  to  the  bone.  The  undivided  tissues 
lying  between  the  bones  on  both  aspects  of  the  limb  are  severed  with  a  scalpel. 
It  is  wise  that  the  interosseous  membrane  and  its  vessels  should  be  divided 
a  short  distance  below  the  point  of  proposed  bone  section,  and  its  borders 
separated  from  those  of  the  contiguous  bones  up  to  the  point  of  section  with 
the  scalpel.  And,  too,  the  blade  should  be  withdrawn  with  each  section  of  the 
membrane;  for  to  turn  it  while  between  the  bones 
lacerates  and  unnecessarily  injures  the  soft  structures. 
This  course  avoids  the  risk  of  cutting  the  vessels  too 
short,  as  occurs  when  they  are  divided  at  a  level  with 
the  bones,  which  procedure  permits  them  to  retract 
above  the  point  of  easy  access.  The  muscles  are 
then  drawn  upward  with  the  three-tailed  retractor 
(Fig.  497),  and  the  bones  sawed  at  the  highest  point 
of  exposure,  the  radius  being  divided  first.  Having 
secured  the  radial,  ulnar,  anterior  and  posterior  inter- 
osseous arteries,  the  wound  is  then  properly  united 
(Fig.  534),  drained,  and  dressed. 

The  Equilateral  Shin-flap  Method. — With  the  fore- 
arm midway  between  supination  and  pronation  the 
flaps  are  raised  either  from  the  radial  and  ulnar  bor- 
ders or  the  dorsal  and  palmar  surfaces  of  the  forearm, 

the  latter  course  being  most  frequently  adopted.     The    ^     ^„,     o..  j>^^ 

1        xn      4?  ,-.      n         .     -,   ,         .      i  .     J         ^  Fig-  534.— Stump  after 

length  ot  the  flaps  is  determined  m  the  same  manner        circular  operation. 

as  for  the  circular,  plus  an  inch  for  special  retraction ; 

in  fact,  if  the  incision  be  made  first,  and  the  angles  of  the  cuff  trimmed  off 
down  to  near  the  site  of  muscular  section,  the  flaps  will  thus  be  formed. 
It  is  better,  however,  to  mark  them  out  before  incision,  since  to  make  each 
with  the  same  curve  and  same  breadth  of  base  is  not  an  easy  task  without 
this  precaution.  The  remaining  steps  of  the  amputation  are  similar  to  those 
of  the  circular  method.  Jacohson  advises  that  the  posterior  flap  be  made  an 
inch  longer  than  its  fellow  to  provide  for  the  greater  retraction  of  the  integu- 
ment of  that  aspect  of  the  part. 

The  M'usculo-cutaneous-flap  Method. — The  musculo-cutaneous  flap  is 
made  by  transfixion  and  cutting  outward,  or  cutting  from  without,  the  for- 
mer plan  being  commonly  employed.  Either  plan  of  action  is  best  fitted  for 
the  upper  half  of  the  forearm,  on  account  of  the  large  muscular  development 
at  that  situation  (Fig.  224).  Owing  to  the  great  degree  of  muscular  retrac- 
tion here,  the  making  of  the  flaps  should  be  carefully  planned  and  executed. 


AMPUTATIONS. 


481 


The  width  of  the  base  and  the  length  of  eacli  should  equal  one  half  the  cir- 
cumference of  the  limb  at  the  point  of  proposed  amputation.  It  will  not  be 
amiss,  in  cases  of  large  muscular  development,  to  increase  the  length  some- 
what, on  account  of  the  unusual  contraction  incident  to  this  class  of  cases. 
The  remaining  steps  differ  in  no  essential  degree  from  those  of  other  methods 
of  procedure. 

The  Comments. — The  placing  of  the  cicatrix  at  the  end  of  the  stump  in 
the  arm,  even  when  followed  by  its  adhesion  to  the  underlying  tissues,  is 
less  objectionable  than  at  the  end  of  a  weight-bearing  stump,  for  apparent 
reasons.  The  circular  method  is  not  advisable  at  the  upper  two  thirds  of 
the  arm  because  of  the  large  amount  of  muscular  structure  there. 

The  Results. — Of  2,933  cases  of  amputation  of  the  forearm  during  the 
preaseptic  period,  16.34  per  cent  died;  of  478  operations  under  asepsis, 
only  3.09  per  cent  terminated  fatally. 

Amputation  at  the  Elbow  Joint  {Disarticulation). — The  elliptical-flap, 
the  circular,  and  the  anterior  single-flap  methods  are  commonly  employed. 

The  Anatomical  Points. — Before  operation  carefully  define  the  location 
of  the  most  prominent  portions  of  the  condyles  of  the  humerus.  The  inter- 
nal condyle  is  about  one  inch  and  the  external  about  three  fourths  of  an  inch 
above  the  articulation.  Just  below  the  outer  condyle  is  felt  the  moval)le 
head  of  the  radius ;  about  an  inch  below  the  inner  condyle  the  ulna  joins  the 
humerus ;  the  articulation  is  therefore  oblique,  the  inner  portion  being  about 
half  an  inch  the  lower,  owing  to  the  inner  condyle  being  that  much  longer 
than  the  outer.  The  anterior  crease  of  the  integument  is 
just  above  the  joint.  The  integument  on  the  anterior  and 
radial  sides  of  the  joint  retracts  freely,  while  that  on  the 
posterior  has  little  tendency  to  retract,  and  is  well  inured 
to  pressure  by  previous  use. 

The  Elliptical-flap  Method. — The  elliptical  method 
can  be  practiced  by  making  the  ellipse  either  on  the  an- 
terior or  posterior  surface  of  the  limb. 

The  Anterior  Ellipse. — In  this  method  the  olecranon 
process  marks  the  highest  point  of  the  ellipse  behind; 
the  anterior  point  of  the  ellipse  is  just  above  the  middle 
of  the  forearm  in  front  (Fig.  535).  The  flap  is  outlined 
by  an  incision  made  through  the  skin  only,  extending 
from  the  olecranon  around  in  front  and  back  to  the  point 
of  starting.  The  forearm  is  then  slightly  flexed,  the  flesh 
pinched  up  and  transfixed  down  to  the  bone  close  to  the 
joint  through  the  beginning  of  the  preceding  incision, 
and  the  knife  carried  downward  and  forward  along  the 
same  line  to  the  completion  of  the  flap.  The  flap  is 
then  drawn  upward  and  disarticulation  is  performed  the 
same  as  before.  The  union  of  the  borders  of  the  wound  results  in  a  poste- 
rior cicatrix. 

The  Posterior  Ellipse.— In  this  method  the  points  of  the  ellipse  are 
reversed,  the  flap  being  taken  from  the  posterior  surface.    There  is  nothing 


Fir.  535.— The  ellip- 
tical-flap method. 


482 


OPERATIVE  SURGERY. 


to  commend  this  plan  in  the  place  of  the  former.     In  this  amputation  a 
drainage  tube  should  be  employed  for  the  first  few  days  of  the  treatment. 

The  Circular  Method. — Lay  out  the  flaps  obliquely,  measuring  from  the 
condyles — four  inches  below  the  outer  and  two  and  a  half  inches  below  the 
inner  condyle.     Divide  the  superficial  tissues  obliquely  down  to  the  fascia 


Fig.  536. — Circular  amputation 
at  elbow  joint. 


Fig.  537. — Stump  in  circular 
amputation  at  elbow. 


surrounding  the  muscles ;  dissect  the  flap  upward  to  a  level  with  the  joint, 
the  bony  landmarks  to  which  should  again  be  carefully  determined.  Forci- 
bly extend  the  arm  and  make  an  oblique  incision  in  front  on  the  line  of  the 
articulation  into  the  joint ;  sever  the  internal  and  external  lateral  ligaments, 
and  press  the  arm  still  farther  backward;  draw  the  olecranon  process  for- 
ward into  the  wound,  and  sever  its  connection  with  the  triceps  (Fig.  536). 
Unite  the  borders  of  the  flap  as  indicated  in  the  figure  (Fig.  537).  The 
flaps  can  also  be  united  from  before  backward,  which  causes  the  cicatrix 
to  fall  between  the  condyles,  and  likewise  increases  the  drainage  facilities — 
two  very  important  indications. 

The  Anterior  Single-flap  Method. — The  single  flap  can  be  made  either  of 
integument  and  subcutaneous  tissue  alone  or  it  may  be  musculo-cutaneous, 
and  formed  by  transfixion.  In  either  instance  it  should  be  taken  from  the 
anterior  surface  of  the  forearm.  If  made  hy  transfixion  (Fig.  538),  supinate 
and  flex  the  forearm  slightly,  raise  the  soft  parts  in  front  of  the  joint  and 
enter  the  knife  an  inch  below  the  inner  condyle,  pass  it  in  front  of  the  bones 
obliquely  outward,  causing  it  to  escape  about  two  inches  below  the  outer 
condyle.  Cut  the  anterior  flap  downward  and  outward,  making  it  about 
four  inches  and  a  half  in  length,  the  radial  side  being  the  longer,  because  of 
greater  retraction  there;  dissect  and  draw  the  flap  up  to  a  level  with  the 
joint  in  front.  Make  the  posterior  flap  by  connecting  the  extremities  of  the 
flrst  incision  by  a  slightly  convex  one  of  the  skin  alone,  or  including  the 


AMPUTATIONS. 


483 


muscular  tissues  (Fig.  539) ;  dissect  this  up,  after  which  the  Joint  is  opened 
in  front,  the  lateral  ligaments  are  divided,  the  olecranon  process  is  displaced 
forward,  and  the  triceps  cut  off. 

The  Comments. — In  amputations  at  the  elhow  the  variety  and  location  of 
the  flap  must  be  regulated  largely  by  the  state  of  the  tissues.  Imperfect 
soft  parts  at  one  aspect  necessitate  a  proportionate  increase  of  the  flap  of 
the  opposite  surface.  Therefore,  it  should  be  remembered  to  seek  flaps 
wherever  they  may  be  found,  rather  than  impair  the  usefulness  of  the 
stump  by  sacrifice  of  bone. 

It  is  advisable,  when  possible,  to  saw  off  the  olecranon,  allowing  it  to 
remain  with  the  triceps  attached.  If  it  be  possible  to  sever  the  ulna  below 
the  insertion  of  the  brachialis  anticus,  allowing  the  fragment  to  remain  along 
with  its  muscular  attachments,  the  stump  will  be  more  serviceable.  In 
amputations  near  the  elbow,  the  tubercle  of  the  radius,  together  with  the 
biceps  tendon  inserted  into  it,  should  be  carefully  preserved  when  possible. 

The  anterior  elliptical  and  the  anterior  single-flap  method  each  provides 
an  ample  and  well-nourished  flap,  good  drainage,  and  suitably  locates  the 


Fig.  538. — Anterior  flap  by  transfixion. 


Fig.  539. — Making  posterior  flap. 


cicatrix.  Of  the  two,  the  former  is  somewhat  the  better  plan;  each  is  the 
antithesis  of  the  posterior  elliptical  in  these  respects.  The  circular  method 
although  causing  a  limited  loss  of  the  soft  parts  covers  less  satisfactorily  the 
end  of  the  stump  and  places  the  cicatrix  there. 

The  Results. — Of  332  amputations  in  this  situation  for  various  causes, 
done  before  asepsis,  14.15  per  cent  died;  in  252  cases  done  under  asepsis 
the  mortality  was  3.57  per  cent. 

Amputation  of  the  Arm. — The  arm  can  be  amputated  by  the  circular- 
flap  method,  the  irregular  double  flap,  the  antero- posterior  flap,  the  sin- 
gle circular  incision  of  Celsus  (Fig.  637),  and  by  Teale's  method.  The 
circular-flap  methods  are  applica1)le  especially  to  the  lower  portion  of  the 
arm;  the  remaining  methods  are  better  adapted  to  the  upper  portion,  and 
each  can  be  employed  as  circumstances  require. 

The  Circular-flap  Method. — The  circular-flap  method  can  be  practiced 
in  either  of  two  ways :  First,  the  length  of  the  flap  is  made  to  conform  to 
one  fourth  of  the  circumference  of  the  limb,  plus  an  additional  inch  to  pro- 


484 


OPERATIVE  SURGERY. 


vide  for  retraction.  Divide  the  superficial  tissues  down  to  the  muscular 
fascia  and  turn  the  flap  up  as  elsevi^here  (Figs.  474  and  475) ;  then  divide 
the  muscles  about  an  inch  below  the  reflection  of  the  flaps  down  to  the 
bone.  Apply  the  two-tailed  retractor  (Fig.  499),  saw  through  the  bone 
opposite  the  point  of  reflection  of  the  flap,  and  unite  the  flaps  in  the  direc- 
tion best  calculated  to  provide  dependent  drainage.  Second,  divide  the  in- 
tegument the  same  as  before,  free  it  at  the  border  from  the  intermuscular 
septa,  draw  the  flap  upward  gently  and  with  a  long  knife  make  a  circular 
sweep  around  but  not  entirely  through  the  muscles,  draw  up  the  divided 
muscular  fibers  and  repeat  the  circular  sweep,  going  this  time  down  to  the 
bone.  This  manoeuvre  makes  the  cone-shaped  arrangement  of  the  end 
(Fig.  634).     In  other  respects  the  operations  are  similar. 

The  Irregular  DouUe-flap  Method. — If  skin  alone  be  employed,  the  un- 
equal flaps  should  be  carefully 
mapped  out  upon  the  integument  of 
the  arm.  Dissect  these  up,  and  an 
inch  below  the  flap  reflection  make 
a  circular  section  of  the  muscles 
down  to  the  bone ;  unite  the  flaps 
and  dress  the  stump. 

The  Remarks. — The  irregular- 
flap  method  is  advantageous  in  the 
saving  of  bone,  when  irregular  in- 
jury or  disease  of  the  surface  of  a 
limb  requires  either  this  kind  of  flap 
or  else  a  sacrifice  of  leverage  to 
secure  uniform  ones.  The  base  of 
each  flap  should  equal  one  half  the 
circumference  of  the  limb.  If  the 
condition  of  the  soft  parts  will  per- 
mit, the  length  of  the  anterior  flap 
is  made  equal  to  the  circumference 
of  the  limb,  the  posterior  to  half 
that  distance. 

The  Antero-posterior  flap  Meth- 
od.— The  antero-posterior  flaps  can 
be  made  of  skin  alone  or  combined 
with  muscle.  In  the  former  instance 
they  are  fashioned  and  raised  as  is 
already  elsewhere  indicated. 

If  museulo-cutaneous  flaps  (Lan- 
genbeck)  be  desired,  they  can  be 
made  by  transfixion  and  cutting  from  within  outward  with  a  long  knife,  or 
from  without  inward  with  a  scalpel.  The  latter  plan  secures  better  uni- 
formity of  outline  of  the  flap.  If  made  by  cutting  from  without,  outline 
them  carefully  (Fig.  540),  and  when  dissected  up  the  desired  distance, 
finish  the  operation  by  a  complete  division  of  the  muscles. 


Fig.  540. — Langenbeek's  method. 


AMPUTATIONS. 


485 


The  large  anterior  and  small  posterior  sMn-flap  method  is  sometimes  per- 
formed (Fig.  541),  also  one  with  a  large  anterior  flap  and  a  posterior  circular 
incision  (Fig.  542).  These  flaps  possess  the  advantage  of  good  drainage  and 
of  placing  the  cicatrix  where  it  is  well  removed  from  irritation.  The  dimen- 
sions of  the  flaps  can  be  easily  estimated  on  the  basis  of  recijjrocal  length — viz., 
if  one  be  increased  in  length,  the  other  should  be  proportionately  shortened. 
TeaWs  Method. — Teale's  method  when  employed  should  be  done  at 
the  lower  portion  of  the  arm,  the  long  flap  being  taken  from  the  antero-ex- 

ternal  surface,  in  order  that  the  short  one 
shall  contain  the  nerves  and  the  brachial 
artery. 


Fig.  541. — Unequal  skiu  flaps, 


Fig.  542. — Large  anterior 


Amputation  at  the  Surgical  Neck  of  the  Humerus. — Two  methods  of 
amputation  are  practiced,  in  either  of  which  the  bone  is  divided  just  above 
the  insertions  of  the  tendons  of  the  pectoralis  major  and  the  latissimus  dorsi 
muscles.  This  amputation  is  characterized  by  special  considerations,  such 
as  the  avoidance  of  the  line  of  epiphyseal  junction,  of  the  bursa  of  the  sub- 
scapular tendon  on  account  of  its  frequent  communication  with  the  shoulder 
joint,  and  of  the  vessels  and  nerves  associated  with  the  surgical  neck  of  the 
bone.  The  operation  can  be  employed  for  uncomplicated  cases  in  those 
over  eighteen  years  of  age. 

The  Anatomical  Points. — The  integument  over  the  deltoid  is  thicker, 
more  adherent,  and  less  retractile  than  is  that  over  the  pectoral  muscle  and 
inner  surface  of  the  arm.  With  the  arm  hanging  at  the  side  and  the  hand 
supine,  the  bicipital  groove  looks  forward,  and  the  articular  surfaces  of  the 


486  OPERATIVE  SURGERY. 

head  in  the  same  direction  as  the  inner  condyle.  The  circnmflex  artery  and 
nerve  cross  the  humerus  horizontally  about  three  quarters  of  an  inch  above 
the  vertical  center  of  the  deltoid  muscle — an  important  fact,  especially  in 
excision  (page  387). 

The  Oval  Method  (Gruthrie). — Arrest  the  circulation  of  the  subclavian  by 
direct  or  elastic  pressure,  raise  the  arm  from  the  side  of  the  body,  begin  the 
cutaneous  incision  two  fingers'  breadth  beneath  the  acromion  process,  carry 
it  to  the  inner  side  of  the  arm  just  below  the  border  of  the  pectoralis  major 
muscle,  then  beneath  the  arm  to  the  outside,  where  it  is  joined  by  a  second 
incision  carried  backward  from  the  beginning  of  the  preceding  one.  The 
integument  is  retracted  and  the  muscles  of  the  flap  are  severed,  the  bone  is 
exposed  up  to  the  great  tuberosity,  the  circumflex  vessels  and  nerves  are 
drawn  upward  with  a  hook,  and  the  bone  is  sawed  through.  The  large 
nerves  are  cut  short.  If  the  circumflex  vessels  can  not  be  withdrawn  from 
danger  they  should  be  tied  and  divided. 

The  Single  External-flap  Method  (Farabeuf). — An  integumentary  U- 
shaped  flap  with  the  base  equal  in  width  to  one  half  the  circumference  and 
the  length  to  the  diameter  of  the  extremity  is  made  with  the  base  two 
inches  below  the  surgical  neck.  The  muscular  tissue  is  divided  by  trans- 
fixion, and  cutting  outward  in  the  line  of  the  integumentary  incision.  The 
tissues  at  the  inner  aspect  of  the  limb  are  divided  singly  and  with  care  as 
follows :  Expose  the  bone  below  the  bicipital  groove ;  divide  the  periosteum 
at  that  point  and  detach  it  upward  along  the  groove  with  an  elevator,  in- 
cluding the  insertion  of  the  greater  part  of  the  pectoral  muscle  ;  divide  the 
tendon  of  the  long  head  of  the  biceps  low  down,  avoiding  injury  of  the 
synovial  sheath  and  also  of  the  bursa  of  the  subscapularis  tendon.  Expose 
and  tie  the  main  vessels  before  their  division,  cut  short  the  nerves  and  sever 
the  tendinous  insertions  close  to  the  bone.  The  flaps  are  united  and  dressed 
in  the  usual  manner.  Amputations  at  this  situation  are  regarded  as  less 
fatal  than  disarticulation  at  the  shoulder  joint,  and,  moreover,  the  rotundity 
of  the  joint  is  better  preserved,  and  the  stump  offers  a  better  opportunity 
for  the  attachment  of  an  artificial  limb. 

The  Remarks. — The  circular  method  is  better  adapted  to  the  lower  and 
the  flap  method  to  the  upper  half  of  the  arm.  In  amputations  of  the 
humerus  during  childhood  the  disproportion  of  the  growth  in  the  bone 
and  soft  parts  is  liable  to  result  in  a  conical  stump.  It  happens  not  in- 
frequently in  these  cases  that  repeated  exsection  of  the  distal  end  of  the 
elongating  bone  is  required  to  relieve  pain  and  discomfort  at  the  end  of  the 
stump. 

The  Results. — In  8,050  amputations  of  the  arm  for  all  causes,  of 
7,457  done  before  antisepsis,  29.5  per  cent  died;  of  593  with  asepsis,  12.4 
per  cent  died — about  eighteen  per  cent  when  done  in  the  upper  third,  six- 
teen per  cent  at  the  middle  third,  and  about  twenty-six  per  cent  at  the  lower 
third — the  greater  per  cent  in  this  situation  being  due,  no  doubt,  to  the 
greater  degree  of  the  injury  calling  for  amputation  at  this  point. 

Amputation  at  the  Shoulder  Joint  (Pwar^icMZa^iow). — There  are  various 
methods  recommended  for  amputation  at  this  joint.    It  is  hardly  necessary 


AMPUTATIONS. 


487 


to  enter  into  the  details  of  more  than  those  which  are  commonly  recognized 
and  employed.  The  remainder,  while  ingenious  in  many  instances,  do  not 
present  sufficient  practical  differences  to  entitle  them  to  introduction  into 
other  than  cyclopjsdic  treatises  of  operative  surgery. 

Foiir  methods  of  amputation  will  be  described  :  The  external-  and  in- 
ternal flap-method^  the  circular  method,  the  racket  methods  of  Larrey  and 
Spence. 

The  special  considerations  incident  to  disarticulation  at  this  joint  may 
be  briefly  stated  as  follows :  1,  The  control  of  haemorrhage ;  2,  the  main- 
tenance of  the  symmetry  of  the  shoulder ;  3,  the  transverse  division  of  the 
axillary  vessels  and  high  division  of  the  nerves ;  4,  the  prevention  of  entry 
of  air  into  the  veins;  5,  the  establishment  of  good  drainage;  6,  the  least 
possible  division  of  tissue  ;  7,  the  easy  disarticulation ;  8,  the  formation  of  a 
serviceable  stump. 

Hemorrhage  may  le  prevented  by  direct  pressure  of  the  subclavian  on 
the  first  rib  by  the  thumb,  a  padded  key,  or  the  padded  extremity  of  a  short 
crutch,  or  the  artery  may  be  ligatured  here  for  the  purpose.  Which  expe- 
dient is  the  best,  depends  very  much  indeed  on  the  quietude  and  condition 
of  the  part ;  for,  if  the  shoulder  be  pushed  upward  during  the  operation, 


Fig.  543. — Shoulder-joint  amputation.     Pins   and   rul)ber-tube    tourniquet   in   position. 
The  Esinarcli  bandage  is  removed  from  arm. 

the  compressing  agent  may  be  displaced  l)y  movements  of  the  clavicle^  if 
the  tissues  be  thickened  by  disease,  or  otherwise,  direct  pressure  may  be  inef- 
ficient for  the  purpose.  The  employment  of  elastic  constriction,  as  figured 
(Fig.  545),  or  with  the  aid  of  Wyeth's  needles  (Figs.  543  and  544),  may 
answer  well  throughout  unless  the  vessel  be  compressed  against  the  head  of 


488  OPERATIVE  SURGERY. 

the  humerus.  When  thus  compressed,  hsemorrhage  will  probably  occur 
when  the  bone  is  removed.  Before  division  of  the  vessels,  however,  the  tis- 
sues containing  them  can  be  firmly  grasped  by  the  hand  above  the  point  of 
section,  and  thus  the  bleeding  will  be  prevented  in  any  instance.  Symmetry 
is  maintamed  to  the  fullest  extent  by  the  preservation  of  the  deltoid,  the 


Pig.  544. — Appearance  al'ter  disarticulation  and  ligature  of  the  vessels. 


acromion  process,  and  the  circumflex  nerves  and  arteries;  division  of  these 
nerves  and  arteries — the  former  especially — leads  to  muscular  atrophy. 
Transverse  division  of  the  vessels  is  easily  made  by  cutting  the  tissue  con- 
taining them  at  right  angles  while  taut.  Tligli  division  of  the  nerves  is  easily 
performed  by  pulling  down  upon  them  before  section.  The  entrance  of  air 
is  prevented  by  prompt  closure  of  the  open  mouths  of  the  veins  (page  123). 
The  remaining  four  special  considerations  will  be  recalled  in  connection 
with  their  exemplification  by  operative  method. 

The  External-  and  Internal-flap  Method  (Dupuytren). — Place  the  pa- 
tient at  the  edge  of  the  table,  and  turned  toward  the  healthy  side,  with  the 
body  raised ;  make  an  external  oval  flap  by  an  incision  extending  from  the 
coracoid  process  downward  and  outward  to  the  insertion  of  the  deltoid,  then 
upward  and  backward,  terminating  at  the  junction  of  the  acromion  process 
with  the  spine  of  the  scapula  (Fig.  545).  Eaise  the  flap,  including  the 
deltoid  muscle,  as  far  as  the  acromion,  expose  the  capsule  of  the  joint,  push 
upward  the  head  of  the  humerus,  and  divide  the  capsule  above;  rotate  the 
arm  outward,  sever  the  subscapularis ;  then  inward,  and  divide  rapidly  the 
external  rotators  attached  to  the  greater  tuberosity.     While  the  arm  is 


AMPUTATIONS. 


489 


rotated  internally,  divide  the  capsule  still  further,  together  with  the  tendon 
of  the  long  head  of  the  biceps;  tilt  the  head  of  the  humerus  outward,  pass 
tlie  blade  of  the  knife  beneath  it  (Fig.  546) ;  seize  the  head  of  the  bone  and 
draw  it  outward,  carry  the  knife  along  its  inner  surface  until  within  about 

four  inches  below  the 
axillary  fold,  then 
turn  the  edge  inward 
and  complete  the  flap. 
The  last  sweep  of  the 
knife  severs  the  prin- 
cipal vessels.  This 
flap  should  be  seized 
by  an  assistant  and 
tightly  grasped  be- 
fore it  is  divided. 
The  appearance  of 
the  wound  after  the 
operation  is  repre- 
sented in  Fig.  547. 

The  Circular-in- 
cision Method. — Con- 
trol the  circulation 
as  before.  Abduct 
the  arm  and  make  a 
circular  incision  en- 
tirel}'  around  it  sever- 
ing all  the  tissues, 
down  to  the  bone,  at 
a  level  corresponding 
to  the  insertion  of 
the  deltoid.  Ligature 
the  vessels  and  saw 
off  the  bone.  Make 
a  second  incision  lon- 
gitudinally from  the 
anterior  border  of  the 
acromion  the  whole 
length  of  the  stump 
down  to  the  bone. 
The  bone  is  first  held 
firmly  and  the  soft 
parts  are  separated 
from  it  (Fig.  548), 
then  it  is  rotated  out- 
ward and  inward,  to  admit  of  the  division  of  the  muscular  and  fibrous  attach- 
ments to  its  head,  after  which  it  is  removed. 

The  BemarJcs.— This  operation  is  a  good  one,  well  calculated  to  provide 

oo 


Fig.  545.— Disarticulation  of  shoulder  joint,  making  outer 
flap ;  elastic  circular  compression. 


490 


OPERATIVE  SURGERY. 


Fig.  546.— Making  inner  flap. 


^"^^JP^' 


Pig.  547. — Appearance  of  the  stump. 


Fig.  548. — Circular  incision  method,  removing  bone. 


AMPUTATIONS. 


491 


favorable  drainage  (Fig.  549),  and  is  done  with  a  minimum  amount  of  injury 
to  the  soft  parts.     If  the  periosteum  be  separated  from  the  bone  without 
disturbing  the  surrounding  soft  parts  there  will  be  less  danger  of  the  exten- 
sion of  inflammatory  action  be- 
yond the  line  of  the  longitudinal 
incision;  moreover,  a  greater  de- 
gree  of   firmness   will  be   given 
the  stump  even  though  new  bone 
be  not  i^roduced. 

Tlie  Oval-flap  Method  (Lar- 
rey). — The  oval  method  is  well 
regarded,  and  is  performed  by 
making  a  vertical  incision  from 
just  below  the  extremity  of  the 
acromion  process,  with  the  arm 
extended,  about  three  inches  in 
length,  down  to  the  bone;  this 
incision  should  terminate  about 
two  inches  below  the  head  of  the 
humerus.  Two  oblique  incisions 
are  then  made,  each  beginning 
near  the  middle  of  the  vertical 
cut,  one  on  the  anterior  and  the 
other  on  the  posterior  aspect  of 
the  limb,  and  are  carried  through 
the  lower  borders  of  the  struc- 
tures comprising  the  anterior 
and  posterior  walls  of  the  axilla, 
at  the  points  where  these  borders 

connect  with  the  arm,  thus  severing  their  attachments  to  the  humerus 
(Fig.  550).  The  soft  parts  at  the  inner  aspect  of  the  humerus  still  remain 
undivided.  The  borders  of  the  wound  are  now  drawn  apart,  the  joint  is  ex- 
posed and  opened  above,  the  bone  is  drawn  downward  to  separate  the  joint 
surfaces,  the  blade  of  the  knife  passed  behind  the  luxated  bone,  and  the 
operation  is  completed  by  cutting  the  tissues  remaining  at  the  inner  side  of 
the  humerus  (Fig.  551). 

The  Racket-flap  Method  (Spence). — The  racket-flap  method  has  attracted 
considerable  attention,  and  is  certainly  entitled  to  great  consideration.  The 
operation  is  performed  in  the  following  manner :  Abduct  the  arm  slightly, 
rotate  the  humerus  outward,  cut  down  upon  the  head  of  the  bone,  beginning 
immediately  external  to  the  coracoid  process,  thence  directly  downward 
through  the  fibers  of  the  deltoid  and  pectoralis  major  to  the  lower  border  of 
the  latter,  which  is  divided ;  carry  the  incision  with  a  gentle  curve  outward 
across  and  through  the  lower  fibers  of  the  deltoid,  to,  but  not  through,  the 
posterior  border  of  the  axilla  (Fig.  552).  Begin  the  inner  incision  at  the 
lower  extremity  of  the  vertical  one,  carry  it  around  the  inner  side  of  the  arm, 
through  the  skin  and  fat  only,  to  meet  the  one  made  at  the  outer  side.    If 


Pig.  549. — Flaps  united,  drainage  introduced. 


492 


OPERATIVE  SURGERY. 


the  fibers  of  the  deltoid  have  been  thoroughly  divided,  the  flap,  together  with 
the  posterior  circumflex  artery,  can  be  easily  separated  by  the  finger  from  the 
bone  and  joint,  and  drawn  upward  and  backward  until  the  head  of  the  bone 


Fig.  550. — Larrey's  method. 


Fig.  551. — Forming  inner  flap. 


is  exposed;  then  the  ligaments  and  muscular  attachments  are  divided,  dis- 
articulation is  accomplished,  and  the  limb  removed  by  dividing  the  remain- 
ing soft  parts  at  the  axillary  aspect. 

The  Remarks. — Spence's  method  is  valuable  because  it  admits  of  a  choice 
between  excision  and  amputation.  In  very  muscular  subjects  a  redundancy 
of  muscular  tissue  in  the  fiap  can  be  avoided  by  dissecting  the  integument 
and  subcutaneous  tissues  a  short  distance  upward  over  the  deltoid,  and  divid- 
ing its  fibers  high  up. 

It  will  be  noted  that  the  external-  and  internal-flap  method  (Fig.  545) 
meets  very  many,  indeed,  of  the  considerations  regarded  as  wise  in  amputa- 
tion at  the  shoulder  joint.  The  oval  method  damages 
the  deltoid  muscle  considerably.  The  circular  and 
Spence's  methods  are  not  much  removed  from  each 
other  in  operative  advantages.  However,  the  latter  is 
the  more  artistic,  and  is  the  more  commonly  employed  of 
the  two. 

The  Results. — Of  1,629  disarticulations  at  the  shoul- 
der joint,  performed  for  all  causes,  1,387  were  done 
before  asepsis,  with  a  mortality  of  37.7  per  cent;  of 
248  cases  done  under  asepsis,  7.7  per  cent  died. 

Amputation  above  the  Shoulder  Joint.— It  may  be- 
come necessary,  on  account  of  malignant  growths  and 
severe  injuries,  to  amputate  the  scapula  together  with  a 
portion  or  the  whole  of  the  clavicle. 

The  operation  is  often  tedious  and  attended  with 
great  loss  of  blood.  Inasmuch  as  the  situation  of  the  dis- 
ease or  injury  calling  for  operation  will  modify  the  location  and  direction  of 
the  incisions,  no  definite  plan  can  be  prescribed.  The  aims  should  always  be  to 
save  enough  healthy  integument  to  cover  the  wound  and  to  avoid  haemorrhage. 


Fig.    552.— Spence's 
method;  racket  flap. 


AMPUTATIONS. 


493 


However,  in  view  of  the  fact  that  the  necessity  for  the  amputation  is  often 
urgent,  it  is  deemed  wise  to  describe  as  briefly  as  possible  the  method  pre- 
sented by  Berger  in  1887.  According  to  Treves,  Berger  divided  the  amputa- 
tion into  four  stages :  "  1.  The  clavicle  is  exposed  and  divided  at  the  junc- 
tion of  the  middle  with  the  outer  third.  The  middle  third  of  the  bone  is 
exsected.  The  subclavian  vessels  are  exposed  and  secured  by  double  liga- 
tures and  divided.  2.  The  antero-inferior  flap  is  fashioned  and  the  brachial 
plexus  severed.  3.  The  postero-superior  flaps  are  fashioned.  4.  The  extrem- 
ity is  removed  by  dividing  the  tissues  still  connecting  the  scapula  with  the 
trunk." 

The  Operation. — The  patient  is  placed  on  the  back  close  to  the  edge  of 
the  operating  table,  with  the  shoulders  elevated  upon  a  hard  cushion.  The 
clavicular  incision  begins  on  the  clavicle  at  the  outer  border  of  the  sterno- 
mastoid  muscle,  and  is  carried  outward  down  to  the  bone  to  just  beyond  the 
acromio-clavicular  articulation  (Fig.  553).    The  periosteum  is  separated  from 

the  underlying  surface  of  the 
middle  portion  of  the  bone  with 
a  periosteal  elevator.  The  clavi- 
cle is  then  drawn  forward  and 
steadied  by  a  blunt  hook  passed 
beneath  it  while  it  is  sawed 
through  at  the  junction  of  the 
inner  and  middle  thirds  with  a 
keyhole,  Gigli-Haertel,  or  fine 
chain  saw.  The  inner  end  of 
the  outer  fragment  is  then  seized 
with  the  forceps  and  drawn  for- 
ward, the  remaining  periosteum 
removed  from  the  middle  third, 
and  the  middle  third  removed 
by  sawing  at  its  junction  with 
the  outer  third.  The  subcla- 
vius  muscle  is  isolated  and  divided  opposite  to  the  inner  section  of  the  bone. 
It  is  then  dissected  up,  the  intervening  fascia  divided,  and  the  deep  vessels 
are  thus  exposed.  The  artery  is  tied  with  two  ligatures  at  the  outer  border 
of  the  first  rib,  and  divided  between  the  ligatures.  The  vein  is  treated  in  a 
similar  manner. 

The  entire  scapular  region  should  now  be  freed  from  the  table,  the  limb 
carried  away  from  the  body,  and  the  head  drawn  in  the  opposite  direction. 
An  incision  is  then  made,  beginning  at  the  center  of  the  clavicular  one,  and 
curved  downward  and  outward  just  outside  the  coracoid  process,  thence  along 
parallel  with  the  anterior  border  of  the  deltoid  muscle  to  where  the  anterior 
fold  of  the  axilla  joins  the  arm,  then  across  the  lower  margin  of  the  pectoralis 
major  transversely  through  the  skin  upon  the  inner  surface  of  the  arm  to  the 
lower  margin  of  the  tendons  of  the  latissimus  dorsi  and  teres  major  muscles. 
The  arm  is  then  raised  and  the  incision  completed  by  carrying  the  knife 
downward  and  inward  along  the  groove  formed  by  the  vertebral  border  of  the 


Fig.  553. — Anterior  and  posterior  (dotted)  lines  of 
incision  in  amputation  above  the  shoulder. 


49* 


OPERATIVE  SURGERY. 


Fig.  554. — Amputation  above 
the  shoulder  joint.  Side 
view. 


scapula  and  the  muscular  mass  formed  by  the  teres  major  and  the  latissimus 
dorsi  muscles,  to  the  posterior  surface  of  the  inferior  angle  of  the  scapula. 
The  flap  is  dissected  forward^  the  pectoralis  major  divided  at  the  tendinous 
parr,  the  pectoralis  minor  close  to  the  coracoid  process,  the  brachial  plexus 

is  exposed  and  the  nerves  are  divided  in  a  line 
with  the  main  vessels.  The  latissimus  dorsi  is 
severed  on  the  line  of  incision,  and  the  shoulder 
falls  outward  from  the  body.  The  arm  is  now 
carried  across  the  chest  so  as  to  expose  the  scapu- 
lar region.  An  incision  is  then  made,  beginning 
at  the  upper  portion  of  the  preceding  one  near 
the  acromio-clavicular  articulation,  and  is  car- 
ried backward  behind  the  shoulder  and  downward 
by  the  shortest  route  over  the  spine  of  the  scapula 
to  join  the  termination  of  the  anterior  incision 
at  the  inferior  angle  of  the  scapula.  This  flap  is 
laid  back  so  as  to  expose  the  trapezius  muscle 
which  is  then  divided  close  to  its  attachments  to 
the  clavicle  and  scapula.  The  flaps  are  now  held 
aside  and  the  superior  and  vertebral  borders  of 
the  scapula  are  rapidly  freed  from  their  muscular  attachments  by  large 
scissors  applied  close  to  the  bone  and  the  part  is  removed.  The  flaps  are 
united  with  sutures,  and  dressings  are  firmly  applied  so  as  to  obliterate  all 
dead  spaces  (Fig.  554). 

The  Comments. — During  the  giving  of  the  anaesthetic  an  Esmarch's 
bandage  may  be  applied  to  the  arm  when  the  nature  of  the  case  approves. 
The  flaps  should  be  modified  in  shape  to  conform  to  the  requirements  of 
the  case.  The  external  anterior  thoracic  nerve  is  a  good  guide  to  the 
vessel,  since  it  passes  upward  between  the  vein  and  the  artery.  Pulsation  is 
the  better  guide,  unless  neutralized  by  shock.  All  ligatures  should  be 
placed  before  being  tightened,  and  the  artery  should  be  tied  first.  The 
suprascapular  vessels  should  be  secured  also.  The  manipulations  of  veins, 
both  large  and  small,  should  be  conducted  with  great  care,  to  avoid  rupture 
and  the  entrance  of  air,  which  appears  to  be  an  especial  danger  at  this  situa- 
tion. The  branches  of  the  brachial  plexus  should  be  severed  on  the  same 
plane  as  the  large  vessels.  The  primary  incision  may  pass  at  once  down  to 
the  clavicle,  and  the  periosteum  corresponding  thereto  should  be  divided 
and  pushed  back.  The  vessels  may  be  controlled  by  pressure  on  the  sub- 
clavian. 

The  Precautions. — In  the  instance  of  displacement  of  the  vessels  by  large 
tumors,  etc.,  insecure  control  of  haemorrhage  may  happen.  Beware  of  shock, 
and  be  prepared  to  meet  it  in  all  of  its  degrees  (page  121). 

Entrance  of  air  is  comparatively  so  common  in  this  operation  as  to  con- 
stitute an  active  danger ;  therefore  the  veins  should  be  tied  as  soon  as  prac- 
ticable. The  surgeon  for  this  reason  ought  to  be  both  alert  and  prepared 
not  only  to  obviate  but  promptly  treat  this  complication  (page  122).  Little 
danger  attends  from  septicaemia. 


AMPUTATIONS.  495 

The  Results. — Of  71  cases  of  this  amputation,  8  died,  6  of  which 
occurred  before  1880,  and  were  due  either  to  hiemorrhage  or  to  infection. 
Ultimate  recoveries,  related  of  course  to  malignant  disease,  are  for  one 
year  and  more  -L6  per  cent  (Eussell  Fowler).* 


*  Annals  of  Surgery,  January  and  February,  1900. 


CHAPTER  X. 

AMPUTATIONS  AT  THE  LOWER  EXTREMITY. 

No  better  or  more  comprehensive  statement  can  be  made  bearing  on  the 
duty  of  the  surgeon  in  amputations  of  the  lower  extremity,  than  that 
"  Under  all  circumstances,  except  where  poverty,  advanced  age,  and  con- 
firmed dissolute  habits  so  combine  in  the  individual  as  to  render  it  certain 
that  mechanical  appliances  would  be  of  little  service,  the  patient  should 
be  given  the  stump  best  adapted  to  the  most  useful  artificial  limbs.  In  all 
amputations  of  the  lower  extremity,  the  surgeon  should  be  governed  in  the 
selection  of  the  point  of  operation  and  the  method  to  be  adopted  by  the  mor- 
tality of  the  operation  in  question ;  by  the  adaptability  of  the  stump  to  the 
most  serviceable  artificial  limb  for  locomotion."  * 

Amputation  of  the  Phalanges  of  the  Toes. — Amputation  is  practiced  in 
the  continuity  of  the  bone  (Fig.  555,  a),  or  through  the  articulations  (disar- 
ticulation), and  is  done  in  the  same  manner  as  amputation  of  the  fingers 
(page  469  et  seq.),  and  therefore  need  not  be  considered  here.  In  the  case 
of  the  toes,  however,  it  is  often  difficult  to  open  the  joints  on  account  of 
the  changes  induced  in  them,  and  in  the  contour  of  the  bones,  by  the  per- 
nicious influence  of  ill-fitting  boots  and  shoes.  The  flaps  are  usually  made 
from  the  plantar  surface. 

In  amputation  at  the  metatarso-pbalangeal  articulations,  it  must  be  re* 
membered  that  the  web  of  the  toes  is  about  an  inch  below  the  Joints  in  ques- 
tion. The  tendinous  sheaths,  the  tendons,  and  the  flap,  are  treated  here  as 
in  amputation  of  the  phalanges  of  the  fingers. 

On  account  of  the  vast  importance  of  the  great  toe  in  connection  with 
the  power  of  serviceable  and  symmetrical  locomotion,  the  amputations  of 
this  member  are  given  a  detailed  attention.  The  remaining  toes  play  a 
subsidiary  part,  indeed,  in  comparison  with  the  great.  Owing  to  the  impor- 
tance of  the  latter,  a  stump  as  long  and  as  serviceable  as  possible  should  be 
constructed. 

Amputation  of  the  First  Phalanx  of  the  Great  Toe.— Flex  the  phalanx 
to  a  right  angle  with  its  fellow,  as  in  amputation  at  the  fingers  make  a 
transverse  incision  with  a  narrow-bladed  knife  in  the  dorsum  of  the  toe 
on  a  line  with  the  center  of  the  long  axis  of  the  second  phalanx;  this 
will  open  the  joint.  Sever  the  lateral  ligaments  separately  with  the  point 
of   the  knife,  then  pass  the  blade  through   the  articulation,  and  carry  it 

*  Prom  report  of  Drs.  Valentine  Mott,  Gurdon  Buck,  John  Watson,  A.  C.  Post,  Wil- 
lard  Parker,  Ernst  Krackowizer,  W.  H.  Van  Buren,  and  Stephen  Smith. 
496 


AMPUTATIONS  AT   THE   LOWER  EXTREMITY. 


497 


Fig.  555. — Amputation  through 
last  phalanx,  great  toe,  and 
second  of  the  adjoining 
(racket  methods). 


forward,  making  a  long  plantar  llap.  If  short  incisions  be  made  down  to 
the  bone  at  each  side  of  the  first  phalanx,  the  liap  can  then  be  formed  with- 
out the  danger  oi  too  great  narrowing  of  £lie  base. 

Another  Method. — With  the  phalanx  extended  make  an  incision  down 
to  the  bone  across  the  dorsal  surface  of  the  first  phalanx,  then  forward 
along  the  outer  side,  nearer  to  the  dorsal  surface,  to  the  distal  extremity 
and  around  this  extremity  to  the  inner  side,  then  backward  in  a  similar 
manner  to  the  inner  end  of  the  transverse  incision.  This  incision  is  made 
down  to  the  bone  throughout  the  entire  course. 
Hyperextend  the  phalanx,  dissect  off  the  flap, 
open  the  joint  from  beneath,  and  sever  the  re- 
maining structures  by  passing  the  blade  upward 
between  the  articular  surfaces. 

Amputation  through  the  last  phalanx  of 
the  great  toe  should  be  practiced  when  possi- 
ble, in  order  to  preserve  the  jjroximal  frag- 
ment for  the  purposes  of  leverage,  and  the 
points  of  insertion  of  the  flexor  and  extensor  ten- 
dons. The  racket  incision  is  best  suited  for  this 
amputation.  The  handle  of  the  racket  begins  at 
the  head  of  the  metatarsal  bone  and  terminates 
near  the  middle  of  the  phalanx  on  the  dorsal  sur- 
face in  lateral  incisions  at  each  side,  which  meet 
on  the  plantar  surface  near  the  distal  extremity  of  the  phalanx  (Fig.  555,  &). 
The  phalanges  of  the  remaining  toes  can  be  removed  in  a  similar 
manner. 

Amputation  of  Single  Toes  (Disarticulation). — Single  toes  can  be  re- 
moved by  the  oval  or  by  the  lateral-flap  method  (Figs.  556  and  557).  The 
former  is  the  better,  and  is  done  as  follows :  The  operator 
grasps  the  condemned  toe,  while  the  assistant  pulls  aside  its 
fellows.  Commence  the  incision  on  the  dorsum  over  the 
metatarso-phalangeal  joint,  carry  it  downward  along  the 
side  of  the  phalanx  to  be  removed,  beneath  the  toe,  through 
the  transverse  line  of  the  web  on  the  sole  of  the  foot.  A 
second  incision  is  then  made  of  a  similar  extent  and  outline 
on  the  opposite  side  of  the  toe.  The  tendons  are  severed, 
the  plantar  and  lateral  ligaments  divided,  and  the  bone 
removed  by  cutting  from  below.  If  the  extremities  of  the 
divided  tendons  remain  exposed  they  are  cut  ofl:  on  a  level 
with  the  divided  border  of  the  soft  parts. 

The  removal  of  either  the  second,  third,  or  fourth  toes 
can  be  well  effected  at  this  situation  by  making  a  transverse 
incision  on  the  dorsum  over  the  joint,  and  passing  the  knife 
through  it  and  along  the  under  surface  of  the  bone  a  suf- 
ficient distance  to  make  the  necessary  plantar  flap,  which 
is  then  turned  upward  and  united.  However,  the  preceding  methods  are 
preferable. 


Fig.  556. — a.  Re- 
moval of  sin- 
gle toe,  oval 
flap.  h.  Re- 
moval of  toe 
with  metatar- 
sal bone. 


498 


OPERATIVE  SURGERY. 


Amputation  of  the  Great  and  Little  Toes  (Disarticulation). — Either  of 
these  toes  can  be  promptly  and  suitably  amputated  by  a  single  lateral-flap 
method.  The  amputation  is  performed  by  abducting  the  toe  and  entering 
the  knife  vertically  between  it  and  the  contiguous  toe,  and  cutting  upward 


Fig.  557. — Lateral-flap  method. 


Fig.  558. — Completion  of  operation,  lateral 
flap,  little  toe. 


through  the  web  till  the  line  of  the  articulation  is  reached,  when  the  knife 
is  turned  from  the  median  line  of  the  foot,  the  joint  opened,  the  blade 
passed  through  it,  and  the  lateral  flap  made  of  sufficient  length  by  cut- 
ting along  the  opposite  side  of  the  toe  (Figs.  557  and  558)  to  be  removed. 
The  importance  of  the  great  toe  as  a  lever  in  propelling  the  body  requires 
that  even  a  part  of  a  phalanx  shall  be  saved  when  practicable.  With  the 
remaining  toes,  however,  it  is  not  a  matter  of  so  much  importance. 

The  prominent  head  of  the  metatarsal  bone  of  the 
great  toe,  which  remains  after  disarticulation,  has  so 
frequently  become  the  seat  of  painful  bunions  that 
many  surgeons  advise  that  the  bone  be  amputated  be- 
hind the  head  by  making  either  a  transverse  or  oblique 
section  of  the  metatarsal  bone.  Of  one  fact  there  can 
be  no  doubt:  the  boot  or  shoe  should  be  kept  from 
contact  with  the  stump  in  these  cases,  otherwise  great 
annoyance  and  needless  crippling  will  result. 

The  Square-flap  Method. — The  great  toe  can  be  am- 
putated by  a  large  square  internal  flap  (Fig.  559). 
Begin  the  longitudinal  incision  at  the  outer  side  of  the 
extensor  tendon  a  little  below  the  joint;  carry  it 
through  the  tissues  down  to  the  first  phalanx  (surgi- 
cal) ;  make  a  transverse  incision  from  the  termination 
of  this  one  around  the  inner  side  of  the  toe  to  a  point 
opposite,  on  the  plantar  surface;  extend  the  toe  and 
make  another  incision  from  the  termination  of  the  last 
toward  the  foot  along  the  outer  side  of  the  tendon  of 
the  flexor  longus  pollicis  to  the  web;  connect  this  incision  with  the  center 
of  the  dorsal  one  by  a  transverse  cut  carried  around  the  outer  side  of  the  base 


Pig.  559.— Square-flap 
method. 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


499 


of  the  toe;  dissect  off  the  flaps  and  divide  the  ligaments  and  remaining 
soft  parts  from  within  outward. 

The  Oval-flap  Method. — In  the  oval-flap  method  the  incision  is  com- 
menced just  above  the  joint  on  the  dorsal  aspect  in  the  median  line,  and  is 
carried  down  to  the  center  of  the  proximal  phalanx  and 
around  it,  avoiding  the  web,  up  to  the  point  of  begin- 
ning (Fig.  560).  The  joint  is  opened  from  below.  The 
cicatrix  is  vertical  and  at  the  end  of  the  bone. 

The  Internal  Plantar-fap  Method  (Farabeuf). — Make 
an  incision,  beginning  at  the  head  of  the  metatarsal  bone 
at  the  line  of  junction  of  the  internal  and  dorsal  surfaces 
of  the  toe,  downward  parallel  with  the  extensor  poUicis 
tendon  for  about  one  inch ;  thence  over  the  inner  surface 
and  across  the  plantar  aspect  of  the  toe  to  the  web  be- 
tween it  and  the  contiguous  toe;  then  between  the  toes 
by  the  shortest  route  to  the  point  of  starting.  The  flap 
is  dissected  back,  the  joint  opened  from  below,  the  ex- 
tremity removed,  leaving  the  sesamoid  bones  behind. 
This  method  provides  a  most  admirable  flap  of  inured 
tissues,  and  places  the  cicatrix  quite  without  the  range  of 
irritation  (Figs.  561  and  562). 

Amputation  of  Two  Adjoining  Toes. — Begin  the  dorsal 
incision  between  the  metatarsal  bones  of  the  toes  to  be 
removed  just  below  the  metatarso-phalangeal  joints ;  carry  it  to  the  farther 
side  of  one  of  the  toes,  making  a  good-sized  flap  from  it,  thence  through  the 
digito-plantar  fold  to  the  opposite  side  of  the  other  toe  back  to  the  point  of 
starting.  Eemove  each  toe  separately  in 
the  usual  manner  and  close  the  w^ound. 


560.— Oval-flap 
method. 


Fig.  561. — Incision 
for  plantar  flap. 


Fig.  562.— Stump  of 
internal  plantar  flap. 


Pig.  563. — Amputation  of  all  the  toes, 

plantar  incision. 


Amputation  of  all  the  Toes  at  the  Metatarso-phalangeal  Joints  (Disar- 
ticulation).— Forcibly  extend  the  toes  with  the  left  hand  and  make  a  curved 
incision  on  the  plantar  surface  from  the  inner  side  of  the  articulation  of  the 
great  toe  to  the  outer  side  of  the  corresponding  joint  of  the  little  toe,  carry- 
ing it  through  the  groove  between  the  sole  of  the  foot  and  the  bases  of  the 


500  OPERATIVE  SURGERY. 

toes  (Fig.  562).  Flex  the  toes  and  join  the  extremities  of  the  first  incision 
by  a  similar  one  carried  across  the  dorsum  (Fig.  564).  Dissect  up  the  flaps, 
expose  the  joints,  and  remove  each  toe  separately,  allowing  the  sesamoid 
bones  of  the  great  toe  to  remain.     If  the  flaps  be  too  short,  the  heads  of 


Fig.  564. — Amputation  of  all  the  toes,  dorsal  incision, 

the  metatarsal  bones  should  be  cut  ofi^  sufficiently  to  permit  proper  adjust- 
ment, and  uniting  of  the  divided  surfaces  of  the  stump  (Fig.  565). 

The  Comments. — Since  the  head  of  the  metatarsal  bone  of  the  great  toe 
is  the  one  most  difficult  to  cover,  the  flap  at  that  situation  should  be 
extended  downward  along  the  inner  side  of  the  toe  to  the  center  of  the 
proximal  phalanx,  and  thence  transversely  outward  across  the  plantar  sur- 
face so  as  to  utilize  a  suitable  portion  of  the  plantar  tissue  of  the  great 
toe  for  the  purposes  of  the  main  flap.  The  sheaths  of  the  flexor  tendons 
should  be  closed  in  the  manner  already  advised  (page  471).  The  flaps 
,.  should  be  united  with  silkworm-gut  sutures, 

the  stump  loosely  dressed,  the  limb  elevated 
somewhat  and  required  to  rest  upon  the  side 
to  facilitate  drainage,  which  may  be  encour- 
aged for  the  first  three  days  by  the  use  of 
wisps  of  horsehair  or  silkworm-gut  introduced 
at  either  extremity  of  the  wound.  Irregular 
flaps  may  be  employed  and  thus  avoid  sacri- 
fice of  bone  for  leverage  purposes.  Careful 
scrutiny  from  time  to  time  is  advisable  to  de- 
-,  tect  the  first  indication  of  inflammatory  ex- 

■-.  tension  along  the  sheaths  of  the  tendons  into 

the  foot.    Evidences  of  such  extension  call  for 

J       prompt  release  of  the  flaps  and  cleansing  and 

y       drainage  of  these  channels. 
FiG.565.-Appearance  of  stump  ^he  Results.— The  general  rate  of  mortal- 

ity in  amputation  of  toes  is  about  six  per  cent. 
Amputation  through  the  Metatarsal  Bones. — Amputation  through  all  of 
these  bones  is  best  accomplished  by  a  short  dorsal  and  a  long  plantar  flap. 
Make  the  plantar  flap  first  by  dissecting  the  tissues  down  to  the  bones  back- 
ward from  the  junction  of  the  toes  with  the  sole  to  the  point  of  amputation. 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


501 


A  short  dorsal  ilap  (Fig.  5()())  is  then  made  with  the  convexity  downward,  its 
extremities  being  united  to  those  of  the  preceding.  Divide  the  interosseous 
tissues  with  a  sharp,  narrow-bladed  knife;  employ  an  antiseptic  six-tailed 
retractor ;  draw  the  soft  parts  upward,  and  divide  the  bones  with  a  fine  saw, 
turn  the  plantar  flap  upward,  and  unite  it  with  the  dorsal  flap  in  the 
usual  manner. 

Amputation  of  the  Great  Toe  with  the  Metatarsal  Bone. — This  ampu- 
tation is  best  done  by  the  oval  or  racket  method  (Fig.  567),  similar  to 
that  for  removal  of  the  thumb.  In  this  in- 
stance the  incision  is  begun  on  the  dorsal 
aspect  of  the  metatarsal  bone  at  the  base, 
and  carried  downward  along  the  bone  at 
the  inner  side  of  the  tendon  of  the  exten- 
sor proprius  hallucis  to  near  the  lower  end 
of  the  bone,  thence  around  the  outer  side 
of  the  toe  to  the  web,  and  across  the  plantar 
aspect  in  the  groove  between  the  toe  and  the 
sole,  finally  curved  upward  across  the  inner 
surface  of  the  toe  to  meet  the  dorsal  incision 
at  the  center  of  the  metatarsal  bone.  The 
flaps  are  laid  off,  and  the  extensor  tendons 
divided  at  the  upper  limit  of  the  incision. 
The  flexor  tendons  are  then  severed,  the 
base  of  the  bone  is  exposed,  the  peroneus 
longus  cut,  the  bone  still  further  exposed,  the  remaining  tendinous  attach- 
ments are  divided,  the  tarso-metatarsal  joint  is  opened,  and  the  extremity 
taken  away.  It  is  recommended,  in  order  to  gain  room,  on  account  of  the 
width  of  the  base  of  the  metatarsal  bone  of  the  toe,  to  make  a  short  trans- 
verse incision  across  it  at  the  tarso-metatarsal  joint. 


Fig.  566. — Sawing  the  bones. 


Fig.  567. — Amputation  of  great  toe  vpith 
the  metatarsal  bone  (oval  method). 


Fig.   568. — Amputation    of   little    toe   with 
metatarsal  bone  (lateral-flap  method). 


Amputation  of  the  Little  Toe  with  the  Metatarsal  Bone. — Amputation 
can  be  done  by  either  the  oval-  or  the  lateral-flap  method ;  the  steps  of  the 
former  method  are  in  all  respects  similar  to  those  for  the  removal  of  the 
great  toe  with  its  metatarsal  bone. 

The  lateral-flap  method  is  performed  by  separating  the  fifth  from  the 
fourth  toe,  at  the  same  time  carrying  a  narrow-bladed  knife  upward  from 
the  web  between  the  fourth  and  fifth  metatarsal  bones  until  it  is  arrested. 


502 


OPERATIVE  SURGERY. 


when  the  knife  is  withdrawn,  and  the  incision  prolonged  upward  on  the 
dorsal  and  plantar  surfaces  on  a  straight  line  about  one  inch.     Strongly 

abduct  the  metatarsal  bone  to 
be  removed,  separating  it  from 
its  fellow  and  from  the  cuboid ; 
carry  the  knife  around  the  base 
to  the  outer  side,  and,  keep- 
ing close  to  the  bone,  downward 
to  the  metatarso-phalangeal  ar- 
ticulation (Fig.  568) ;  remove 
the  bone,  and  the  tongue- 
shaped  flap  will  fit  the  inter- 
metatarsal  incision. 

Amputation  of  the  whole 
or  part  of  a  metatarsal  bone 
of  either  the  second,  third 
(Fig.  556,  &),  or  fourth  toes  can 
be  readily  accomplished  by  ex- 
tending the  stem  of  the  racket 
or  oval  incision  employed  for 
the  removal  of  the  toe  upward 
on  the  dorsal  surface  of  the 
metatarsal  bone  to  the  point 
at  which  the  bone  is  to  be 
divided  for  removal.  Caution 
is  essential  here  to  avoid  in- 
jury to  the  underlying  soft  tis- 
sues during  removal.  There- 
fore the  manipulative  proce- 
dures should  be  directed  espe- 
cially toward  the  bone  itself. 

The  Comments. — In  ampu- 
tation through  all  of  the  meta- 
tarsal bones  dorsal  and  plantar 
flaps  of  equal  length  can  be 
made.  A  single  dorsal  flap  is 
not  advisable,  because  of  its 
thinness  and  the  unfavorable 
site  of  the  scar.  A  flap  taken 
from  the  inner  and  also  one 
from  the  outer  margin  of  the 
foot  may  be  serviceable  in 
Fig.  569. — a,  a.  Line  of  Lisfranc's  amputation,    b.      this    emerffencV- 

Line  of  Hey's  modification  of  Lisfranc's  amputa-  .  ^   .  .     ,,       rn 

tion.  c.  Line  of  Slcey's  modification  of  Lisfranc's  AmpntatlOn    at    tlie    iaiSO- 

amputation.    d.  Line  of  Baudens's  modifica-     metatarsal  Joints  (Lisfranc's). 

tion  of  Lisfranc's  amputation,     'd.  Amputation  -^,        .,,  •,  -,.-1 

tlirough  metatarsal  bones,   e,  e.  Line  of  Porbes's  — -Lt   will  very   mucH   expedite 

amputation.  /,/;/,/.  Lines  of  Mikulicz's  am-  matters,  save  considerable  an- 
putation.    g,  g.  Lines  of  Chopart's  amputation. 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


503 


noyance  to  the  operator,  and  preserve  the  edge  of  his  knife,  if  the  relations 
of  the  bones  entering  into  the  joints  be  fully  noted  before  attempting  dis- 
articulation (Fig.  569).  The  articulation  between  the  cuboid  and  the  fifth 
metatarsal  is  seen  to  be  to  the  inner  side  of  the  tuljerosity  of  the  metatarsal 
bone.  The  articulation  of  the  in- 
ternal cuneiform  and  the  meta- 
tarsal bone  of  the  great  toe  is 
about  an  inch  and  a  half  in  front 
of  the  tuberosity  of  the  scaphoid, 
and  the  base  of  the  second  meta- 
tarsal bone  is  seen  lodged  be- 
tween the  three  cuneiform 
bones.  In  every  instance  these 
joints  must  be  carefully  located. 
The  Operation. — Flex  the 
foot  and  mark  out  on  the  plan- 
tar surface  a  large  semilunar 
flap,  the  base  of  which  shall  cor- 
respond to  the  distance  between 
the  tarso-metatarsal  joints,  first 
and  fifth,  as  just  indicated,  and 
its  distal  extremity  to  the  heads 
of  the  metatarsal  bones.  Extend  the  foot,  and  draw  a  short  dorsal  flap  with 
the  convexity  forward,  its  base  connecting  with  and  corresponding  to  that  of 
the  plantar  flap  (Fig.  570).  Divide  and  draw  the  small  dorsal  flap  upward, 
and  commence  the  disarticulation  at  the  outer  side  of  the  tarsus  just  behind 
tuberosity  of  fifth  metatarsal.  Strongly  extend  and  adduct  the  bones,  which 
will  better  mark  the  lines  of  the  articulation ;  separate  the  fifth,  fourth,  and 


Fig.  570.— Dorsal  flap. 


Fig.  571. — Articulation  of 
second  metatarsal. 


Fig.  572. — Separating  the  second  metatarsal. 


Fig.  573.— Making  plantar  flap. 


third  articulations;  skip  the  second  and  open  the  first.  The  articulation  of 
the  second  with  the  cuneiform  bones  is  peculiar  in  that  it  is  about  two  fifths 
of  an  inch  higher  than  the  first  and  third  (Figs.  571,  h,  and  572).  However, 
with  the  bones  depressed,  a  short  transverse  incision  liberates  its  dorsal  con- 


504 


OPERATIVE  SURGERY. 


Fig.  574. — Appear- 
ance of  flap  (Lis- 
franc's  amputa- 
tion). 


nections  with  the  middle  cuneiform,  after  which  it  is  disconnected  from  the 
internal  and  external  cuneiform  bones,  as  well  as  its  contiguous  metatarsal, 
by  cutting  upward  (Fig.  572).  Open  all  the  joints  well,  divide  the  liga- 
ments at  the  sides  and  plantar  surface,  carry  the  knife  along  the  sole,  and 
make  the  plantar  flap  as  previously  laid  out  (Fig.  573). 
If  the  flap  contains  all  of  the  muscular  tissues  of  the  sole 
it  will  be  too  bulky;  therefore  a  part  should  be  omitted, 
more  especially  that  portion  at  the  hollow  of  the  foot. 

The  plantar  flap  may  be  made  by  transfixion  before 
the  articulations  are  opened ;  this  method  can  not  be 
recommended,  however,  as  the  flap  thus  formed  must 
await  the  completion  of  the  operation  without  facilitating 
it.  Moreover,  if  the  plantar  flap  be  made  by  transfixion 
before  disarticulation,  the  transverse  arch  of  the  foot  will 
be  intact,  causing  the  center  of  the  flap  to  be  made  thin, 
since  the  knife  can  not  come  sufficiently  close  to  other 
than  the  flrst  and  fifth  metatarsal  bones  to  properly  form 
the  flap.  After  the  removal  of  the  part,  the  flap  appears  as  seen  in  Fig.  574. 
The  RemarJcs. — This  method  has  been  variously  modified,  the  modifica- 
tions in  some  instances  becoming  confused  with  the  original  method.  Hey 
sawed  off  the  projecting  portion  of  the  internal  cuneiform  (Fig.  569,  &); 
this,  however,  is  not  expedient,  as  it  lessens  the  attachment  of  the  tibialis 
anticus  and  shortens  the  leverage  of  the  foot. 

Skey  sawed  ofE  the  base  of  the  second  metatarsal,  leaving  it  in  the  mor- 
tise (Fig.  569,  c).  This  adds  nothing  to  the  usefulness  of  the  stump,  and 
exposes  the  remaining  fragment  to  the  danger  of  necrosis. 

i?cmtZe?iS'(Fig.  569,  J) proposed  that  the  first  metatarsal  bone  only  should 
be  disarticulated,  and  the  remaining  ones  sawed  off  transversely  on  a  level 
with  the  internal  cuneiform. 

Smith  (R.  W.)  practiced  a  modification  of  the  operation  which  required 
the  removal  of  the  four  lesser  metatarsal  bones  close  to  the  proximal 
articulations  through  an  oblique  incision  extending  from  a  point  three 
fourths  of  an  inch  in  front  of 
the   base   of   the   fifth   metatar- 
sal bone  to  the  metatarso-phalan- 
geal  articulation  of  the  great  toe. 
The  plan  adds  to  the  leverage  of 
the  stump  and  preserves  the  in- 
ner  and  outer   supports   of   the 
transverse  arch  of  the  foot  better 
than  any  of  the  preceding  modi- 
fications. 

Amputation  through  the  Me- 
dio-tarsal    Joint    (Chopart's). — 

The  medio-tarsal  joint  is  formed  by  the  astragalus  and  os  calcis  behind  and 
the  scaphoid  and  cuboid  bones  in  front  (Fig.  569,  g  g). 

This  compound  articulation  can  be  readily  located  by  drawing  a  trans- 


FiG.  575. — Chopart's  amputation,  inner  incision. 


AMPUTATION   AT  THE  LOWER  EXTREMITY. 


505 


Fig.  576. — Plantar  incision. 


verse  line  across  the  dorsum  of  the  foot,  the  inner  extremity  beginning  just 
behind  the  tuberosity  of  the  scaphoid,  the  outer  extremity  terminating 
about  an  inch  behind  the  tuberosity  of  the  fifth  metatarsal  bone. 

The  Operation. — The  foot  is  raised  and  a  curved  incision  is  carried 
around  the  sole,  extending  from,  the  articulation  of  the  scaphoid  with  the 
astragalus  (Fig.  575)  forward  to 
within  a  thumb's  breadth  of  the 
heads  of  the  metatarsal  bones 
(Fig.  576),  then  across  the  sole 
and  backward  along  the  fifth 
metatarsal  bone  to  the  outer  ex- 
tremity of  the  articulation  of  the 
cuboid  and  os  calcis  (Fig.  577). 
Forcibly  extend  the  foot  and 
make  a  slightly  curved  incision,  through  the  skin  only,  the  convexity  down- 
ward, across  the  dorsum,  connecting  the  extremities  of  the  plantar  incision 
(Fig.  578).  Turn  the  dorsal  flap  upward,  open  the  joint  on  the  dorsal  sur- 
face, beginning  from  within,  depressing  the  metatarsal  bones  toward  the 

heel,  and  severing  the  ligamentous 
connections  thus  made  tense.  Fi- 
nall}^,  pass  the  knife  through  the 
articulation  to  the  plantar  surface, 
turn  the  edge  toward  the  toes  and 
complete  the  plantar  flap  by  cutting 
downward  (Fig.  579).  Fig.  580 
represents  the  stump  after  the 
flaps  are  united. 

The  Remarls. — This  operation 
is  objectionable  on  account  of  the 
liability  of  the  stump  to  become  ex- 
tended, causing  the  patient  to  walk  on  the  cicatrix  at  the  anterior  extremity. 
The  division  of  the  tendo  Achillis  during  or  subsequent  to  the  operation  is 
practiced  to  counteract  this  tendency,  but  frequently  without  permanent 
success.  If  the  stump  be  conflned  in  a  flexed  position  during  the  healing, 
and    for    a    time    afterward, 

there  is  less  danger  of  this     ~'~' "        ,• 

annoying  sequel.    The  sutur-  I 

ing  together  over  the  end  of     ::r^^''^-^_^- 
the  flexor  and  exterior  ten- 
dons may  correct  this  vice. 
The    operation    can    not    be 
recommended  as  a  substitute 
for  those  that  are  to  follow 
in  point  of  comfort  and  usefulness.     Better  service  is  secured  with  an  arti- 
ficial appliance  after  the  Syme  amputation  than  after  Chopart's. 
The  Results. — The  mortality  is  about  eight  per  cent. 
Forbes's  Modification. — While  this  modification  is  accomplished  through 
84 


Fig.  577. — Outer  incision. 


•-^ — - — i 

-^ 

^9" 

, 

■-^ 

^-^ 

. 

^X 

"" — — "~. 

' ""^ 

.„- --.^X^'^^zn; 

?~-^^^^ 

C"""'^— T' 

^—-^ 

-~~~-— _        "'"■ 

^ 

Pig.  578. — Dorsal  incision. 


506 


OPERATIVE  SURGERY. 


substantially  the  same  incisions  as  Chopart's  operation,  still  it  is,  in  point  of 
fact,  a  different  method  rather  than  a  modification.     In  this  the  scaphoid 

and  cuneiform  bones  are  separated, 
and  the  cuboid  is  sawed  through 
on  the  line  of  their  articulation 
(Fig.  569,  e  e).  Inasmuch  as  the 
stump  by  this  operation  is  given 
no  additional  power  of  flexion, 
but  retains  much  of  the  power 
of  extension  of  the  tibialis  pos- 
ticus muscle,  and  all  the  disad- 
vantages of  Chopart's  operation, 
this  method  can  not  be  com- 
mended. 

Irregular  Tarsal  Amputations 
(Molliere). — In  view  of  the  great 
advantages  to  be  gained  by  strict 
use  of  antiseptic  measures  in  pro- 
moting union  by  first  intention, 
limiting  suppuration,  and  lessening 
the  danger  of  necrosis,  it  is  sug- 
gested that  amputations  across  the 
bones  of  the  foot  be  made  irre- 
spective of  the  articulations;  in 
other  words,  that  the  foot  be 
treated  as  if  it  contained  but  one 
bone.  Heretofore  such  measures 
have  been  followed  frequently  by 
necrosis  of  the  fractional  portions  of  the  tarsal  bones  remaining  in  the  stump. 
Sub-astragaloid  Disarticulation. — The  sub-astragaloid  amputation  leaves 


Pig.  579. — Severing  the  posterior  flap. 


Pig.  580. — Appearance  of 
stump. 


Fig.  581. — De  Lignerolles's  amputation,  external 
incision. 


behind  the  astragalus  only,  which  forms  the  end  of  the  stump.     Several 
methods  of  procedure  are  practiced. 


AMPUTATION   AT   THE  LOWER  EXTREMITY. 


507 


Lignerolles's  Amputdllon. — Make  two  lateral  flaps  by  an  incision  begin- 
ning immediately  above  tlie  tuberosity  of  the  os  caleis  on  the  inner  side, 
which  divides  the  tendo  Achillis 
and  is  carried  along  the  outer 
side  of  the  os  caleis  in  a  curved 
direction,  convexity  downward, 
about  an  inch  below  the  external 
malleolus;  thence  extending  ob- 
liquely upward  across  the  middle 
of  the  cuboid  to  the  dorsum  of 
the  foot  (Fig.  581);  then  verti- 
cally downward  across  the  inner 
border  of  the  scaphoid  (Fig". 
582)  till  it  reaches  the  center  of 

the  sole  of  the  foot ;  it  is  then  turned  directly  backward  at  a  right  angle  with 
the  preceding  cut,  and  joins  the  beginning  of  the  incision  at  the  inner  bor- 
der of  the  tendo  Achillis  (Fig.  583). 

Dissect  up  both  flaps  till  the  lateral  surfaces  of  the  os  caleis  and  the 
astragalo-scaphoid  joint  are  exposed,  being  careful  not  to  injure  the  tibio- 
tarsal  joint;  remove  the  bones  in  front  of  the  medio-tarsal  junction;  seize 
the  anterior  extremity  of  the  os  caleis  with  bone  forceps,  depress  and  turn  it 
inward,  and  divide  the  external  lateral  ligaments  with  a  narrow  knife  about 
a  third  of  an  inch  below  the  tip  of  the  malleolus ;  then  divide  the  interosse- 
ous ligament  between  the  os  caleis  and  astragalus ;  finally,  the  talo-calcanean 
ligament  is  divided  an  inch  below  the  internal  malleolus  (Fig.  584).     The 


Fig.  582. — Internal  incision. 


Fig.  583.— Plantar 
incision. 


Fig.  584. — Internal  ligaments. 


OS  caleis  is  then  removed  (Fig.  585)  and  the  flaps  are  united  in  proper 
position.  Fig.  586  shows  the  appearance  of  the  stump  after  union  of 
the  flaps. 


508 


OPERATIVE   SURGERY. 


Fig.  585. 
rolles) 


-Bones  separated  (De  Ligne- 
Bones  sawed  (Hancock). 


The  Results. Over  twelve  per  cent  are  reported  to  have  died  from  the 

operation  alone. 

VerneuiVs  Method.— In  Verneuil's  operation  the  incision  is  begun  at  the 
outer  tuberosity  of  the  os  calcis  about  an  inch  below  the  external  malleolus 

and  carried  forward  to  within  three  fourths 
of  an  inch  of  the  base  of  the  fifth  meta- 
tarsal bone;  then  over  the  dorsum  to  the 
middle  of  the  internal  cuneiform ;  thence 
obliquely  across  the  sole  by  the  shortest 
route  to  the  commencement  of  the  in- 
cision. The  flap  is  raised  and  disarticu- 
lation accomplished  in  the  usual  manner. 
If  the  head  of  the  astragalus  be  too  prom- 
inent it  should  be  sawed  off. 

The  Heel-flap  Method. — In  the  heel- 
flap  operation  begin  the  plantar  incision 
half  an  inch  below  the  external  malleolus,  carry  it  transversely  across 
the  sole  to  within  an  inch  of  the  internal  malleolus.  The  dorsal  in- 
cision is  begun  at  one  end  of  the  plantar  incision  and  is  carried  down- 
ward and  forward  in  a  curved  manner  to  the  astragalo-scaphoid  joint ;  thence 
backward  and  downward,  still  curved,  terminating  at  the  opposite  end  of  the 
plantar  incision.  The  heel  flap  is  dissected  back  to  the  insertion  of  the 
tendo  Achillis,  the  dorsal  flap  is  raised  to  the  astragalo-scaphoid  articula- 
tion, which  is  then  opened,  and  the  blade  passed 
backward  through  the  calcaneo-astragaloid  joint  and 
laterally  so  as  to  separate  the  soft  parts  from  the  os 
calcis  down  to  the  tendo  Achillis,  which  is  then  divided. 
As  before,  the  head  of  the  astragalus  should  be  removed 
if  necessary. 

HancocFs  Operation. — Hancock's  method  of  pro- 
cedure may  be  considered  as  a  combination  of  the  sub- 
astragaloid  and  Pirogoff  methods.  The  operation  can 
be  made  through  incisions  similar  to  those  of  the  latter ; 
the  flaps,  however,  should  be  somewhat  longer.  The 
OS  calcis  is  sawed  as  in  Pirogoff's  method.  A  hori- 
zontal section  of  the  astragalus  is  made  (Fig.  585)  and 
the  detached  fragment  removed,  together  with  the  asso- 
ciated part  of  the  os  calcis,  after  which  the  sawed  sur- 
face of  the  remaining  portion  of  the  os  calcis  is  placed 
in  contact  with  the  under  surface  of  the  articulated 
portion  of  the  astragalus. 

Tripier's  Operation. — By  this  method  of  practice  it 
is  thought  possible  to  prevent  the  retraction  of  the  flap  and  extension  of 
the  stump  by  the  powerful  muscles  attached  to  the  heel,  as  happens  after 
Chopart's  operation.  The  os  calcis  is  divided  on  a  level  with  the  sustentacu- 
lum tali  and  at  a  right  angle  with  the  long  axis  of  the  tibia,  which  makes 
the  cut  surface  of  the  bone  parallel  with  the  ground. 


Fig.  586. — De  Ligne- 
rolles's  method, 
appearance  of  the 
stump. 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


509 


The  Operation. — Bc'<;-in  the  incision  of  tlu;  soft  parts  at  the  outer  border 
of  the  tendo  Achillis,  on  a  level  with  the  outer  malleolus,  carry  it  along  the 
outer  border  of  the  foot  to  the  base  of  the  metatarsal  bone  of  the  little  toe, 
thence  directly  across  the  dorsum  of  the  foot  to  the  base  of  the  metatarsal 
bone  of  the  great  toe ;  from  this  point  it  passes  across  the  sole  of  the  foot, 
forming  there  a  convex  flap  at  least  one  inch  longer  than  the  dorsal  one, 
finally  joining  the  outer  incision  at  an  oblique  angle.  The  flaps  are  dis- 
sected up  sufficiently  to  admit  of  the  disarticulation  of  the  medio-tarsal 
joint  and  of  a  horizontal  section  of  the  os  calcis  just  below  the  sustentac- 
ulum tali.  If  the  bone  be  divided  from  without  inward,  the  posterior  tibial 
artery  is  less  likely  to  be  injured.  The  wound  is  drained,  the  flaps  are 
united,  and  the  stump  is  dressed  antiseptically. 

After-treatment. — The  wounded  part  should  be  kept  raised,  well  venti- 
lated, and  lying  on  the  side.  It  is  better  that  drainage  agents  be  limited  to 
the  openings  than  that  they  should  extend  through  from  side  to  side.  Heel 
flaps  may  be  punctured  longitudinally  for  drainage. 

The  Results. — An  analysis  of  880  cases  of  tarsal  amputations,  includ- 
ing the  methods  of  Lisfranc,  Chopart,  and  the  modifications,  shows  that  of 
638  cases  done  before  asepsis,  22.9  per  cent  died,  and  of  253  operations 
performed  under  asepsis,  8.7  per  cent  died. 

Amputation  at  the  Ankle  Joint — Removal  of  the  Entire  Foot  (Syme's 
Method). — Syme's  amputation  may  be  considered  one  of  the  most  practical 


Fig.  587. — Syme's  method,  outer  incision. 


Fig.  588. — Inner  incision. 


of  the  operations  on  the  foot  and  ankle.  It  is  followed  not  only  by  a  low  rate 
of  mortality,  but  also  by  a  most  serviceable  stump,  either  with  or  without  an 
artificial  appliance.  The  patient  is  placed  upon  a  table  with  the  leg  over- 
hanging it,  the  thigh  raised  by  an  assistant,  who  at  the  same  time  flexes  the 
condemned  foot  upon  the  leg  by  seizing  and  pulling  upward  on  its  anterior 
portion.  The  outlines  of  the  respective  flaps  should  now  be  carefully  drawn 
before  the  incisions  are  commenced.  The  line  indicating  the  proper  course 
of  the  plantar  incision  begins  at  the  apex  of  the  external  malleolus,  and 
with  a  slight  backward  inclination  passes  around  the  foot  (Fig.  587)  to  a 
point  opposite  to  its  beginning,  which  is  about  a  finger's  breadth  below  the 
apex  of  the  internal  malleolus  (Fig.  588). 

The  second  or  dorsal  line  is  drawn  directly  across  the  instep,  and  con- 
nects the  extremities  of  the  plantar  incision. 


510 


OPERATIVE   SURGERY. 


The  Operation. — The  surgeon  selects  a  large  scalpel  with  a  strong 
shank,  and  inserts  the  point  at  the  commencement  of  the  incision  down 
to  the  bone  at  a  right  angle  to  its  outer  surface,  with  the  edge  undermost; 
carries  it  along  the  guiding  line  in  contact  with  the  bone  to  its   inner 

extremity;  places  the  fingers  on 
the  heel  and  the  thumb  within 
the  cut,  and  draws  firmly  back- 
ward on  the  heel  flap,  at  the  same 
time  liberating  it  from  the  outer 
surface  and  sides  of  the  os  calcis, 
back  to  near  the  insertion  of  the 
tendo  Achillis.  An  incision  is 
now  made  down  to  the  bone  on  the  anterior  line ;  the  joint  is  opened  in  front; 
the  foot  is  well  extended,  lateral  ligaments  are  divided,  and  the  foot  is  re- 
moved by  liberating  the  remaining  tissues  attached  to  the  posterior  surface 
of  the  OS  calcis,  including  the  tendo  Achillis ;  always  remembering  to  closely 
hug  the  bone,  else  the  flap  may  be  perforated  and  its  integrity  impaired. 
After  the  removal  of  the  foot,  dissect  up  the  soft  parts  around  the  malleoli  a 
sufficient  distance  to  permit  the  articular  ends  of  the  bones  to  be  sawed  off 
(Figs.  589  and  590) ;  cut  off  the  extremities  of  the  tendons  even  with  the  cut 


Fig.  589. — Bones  of  leg  sawn  through. 


Fig.  590.— Heel  flap. 


Fig.  591.— Flaps  united. 


Fig.  593.— Side  view 
of  stump. 


surfaces  of  the  soft  parts,  bring  the  flap  into  position,  unite  it  in  front 
(Figs.  591  and  593),  and  dress  with  care. 

The  Modifications.—Sawmg  the  malleoli  obliquely  with  a  transverse 
section  of  the  posterior  lip  of  the  tibia  (Fig.  593)  instead  of  removing  them, 
together  with  a  thin  transverse  section  that  includes  the  entire  articular 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


511 


surface  of  the  tibia  as  recommended  by  Mr.  Syme,  is  a  modification  which 
has  been  long  and  somewhat  extensively  practiced.  It  is  believed  to  give  a 
better-shaped  stump,  and  to  be  attended  with  less  danger  to  life  than  if  the 
bony  canals  of  the  tibia  be  freely  opened,  as  in  the  case  of  complete  transverse 
section. 

WyetJi  carries  the  inner  part  of  the  plantar  incision  as  far  forward  as 
practicable  to  add  to  the  nutritive  safety  of  the  flap. 

Many  surgeons,  after  making  the  plantar  incision,  open  the  joint  in  front, 
as  before  described,  disarticulate,  and  then  dissect  the  heel  flap  from  behind 
forward. 

This  course  affords  more  room  and  leverage  to  aid  in  the  removal  of  this 
flap,  but  increases  the  danger  of  cutting  it,  and  also  permits  the  blood  to 
flow  downward  and  interfere  with  the  final 
separation  of  the  heel  flap.  The  removal  of  the 
periosteum  from  the  sides  and  the  posterior 
surface  of  the  os  calcis,  including  the  insertion 
of  the  tendo  Achillis,  has  been  practiced.  If 
this  can  be  done  without  too  much  laceration 
of  its  structure,  it  is  a  commendable  modifica- 
tion. Before  puberty  the  epiphysis  of  the 
tuberosity  of  the  os  calcis  may  be  detached  and 
allowed  to  remain  connected  to  the  heel  flap. 

The  articular  cartilage  remaining  on  the 
extremity  of  the  tibia  is  scraped  off  by  some 
operators ;  this  procedure  is  thought  to  hasten 
the  healing  process.  Many  methods,  adapted 
to  various  forms  of  injury  to  the  soft  parts, 
have  been  devised  to  modify  the  construction 
of  the  flaps  so  as  to  cover  the  end  of  the  stump. 
When  the  formation  of  the  heel  flap  is  impos- 
sible, tissues  can  be  taken  from  all  or  either  of 
the  three  remaining  aspects  of  the  foot,  being 
ever  cautious  to  avoid  injuring  the  posterior 
tibial  artery  where  it  lies  below  the  inner  mal- 
leolus. 

TJie  Fallacies. — The  incision  across  the  in- 
step lies  below  the  line  of  articulation  between 
the  astragalus  and  the  tibia ;  therefore,  unless 
care  be  taken  to  locate  the  joint,  the  operator  will  cut  down  upon  the  neck 
of  the  astragalus,  and,  not  finding  the  joint,  will  become  much  confused  ;  or 
he  may  even  open  the  articulation  between  the  scaphoid  and  astragalus.  If  the 
plantar  flap  be  made  too  long,  it  will  be  impossible  to  carry  it  back  over  the 
point  of  the  heel ;  therefore,  if  it  be  necessary  to  make  a  long  heel  flap,  the 
joint  vshould  be  opened  at  once  from  before  backward,  and  the  heel  flap  dis- 
sected off  from  above  downward.  If  the  dorsal  flap  be  lengthened  for  any 
reason  the  heel  flap  must  be  decreased  correspondingly.  The  saw  line  for 
removal  of  the  articular  surface  of  the  tibia  should  be  made  close  to  the 


Fig.  593.— Oblique  division  of 
malleoli  and  removal  of  pos- 
terior lip. 


512 


OPERATIVE  SURGERY. 


dome  of  the  articulation,  thus  avoiding  needless  sacrifice  of  bone  in  the 
adult  or  involvement  of  the  epiphyseal  cartilage  in  the  young. 

The  Results. — The  rate  of  mortality  from  Syme's  operation  is  from  five 
to  nine  per  cent ;  the  functional  results  are  admirable. 

Eoux's  Method. — Begin  the  incision  at  the  outer  side,  a  little  above  the 
insertion  of  the  tendo  Achillis;  carry  it  straight  forward  beneath  the  outer 


Fig.  594. — Roux's  method.    Outer  incision. 


Fig.  595. — Inner  inci.sion. 


malleolus  (Fig.  594) ;  then  in  a  curved  line  across  the  instep  an  inch  in  front 
of  the  articular  edge  of  the  tibia,  passing  backward  and  downward  on  the 
inner  side  of  the  foot  between  the  inner  malleolus  and  the  tuberosity  of  the 

scaphoid  to  the  sole  (Fig.  595) ;  thence 
obliquely  backward  to  a  point  about  an 
inch  behind  the  tuberosity  of  the  fifth 
metatarsal  bone;  and  finally  backward 
and  upward  over  the  outer  surface  of  the 
heel  to  the  point  of  beginning.  Dissect 
up  the  external  flap,  open  the  joint  at 
the  outer  side,  and  complete  the  internal 
flap  after  disarticulation  of  the  foot.  The 
bones  of  the  leg  should  then  be  divided 
as  in  Syme's  method,  flaps  united,  and 
the  wound  dressed  antiseptically. 
The  Remarks. — This  operation,  while  more  difficult  and  less  satisfactory 
than  Syme's,  can  be  wisely  employed  when  for  any  reason  the  latter  is  of 
doubtful  utility. 


Fig.  596. — PirogoflE's  amputation. 
Lines  of  section  of  os  calcis. 


Fig.  597.— PirogofE's  amputation.    Inner  incision. 


Pig.  598. — Outer  inci.sion. 


PirogoflTs  Amputation. — Pirogofl''s  operation  is  osteoplastic  in  character, 
and  consists  in  the  application  of  the  sawed  surface  of  the  posterior  portion 
of  the  OS  calcis  (Fig.  596)  to  the  sawed  surfaces  of  the  bones  of  the  leg.    The 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


513 


Fig.  599. — Separatiug  articu- 
lar surfaces. 


length  of  the  limb  is  well  preserved,  and,  without  the  use  of  an  artificial 
appliance,  the  stump  is  often  superior  to  that  of  Syme's  operation. 

The  Operation. — Flex  the  foot  at  a  right  angle 
with  the  leg;  make  an  incision  from  the  tip  of 
the  internal  malleolus  across  the  sole  a  little  in 
front  of  the  long  axis  of  the  tibia  (Fig.  597),  to  a 
point  in  front  of  the  apex  of  the  external  malle- 
olus down  upon  the  bone  (Fig.  598),  and  dissect 
the  flap  backward  from  the  os  calcis  for  about  a 
quarter  of  an  inch. 

Connect  the  extremities  of  this  incision  l)y 
another  carried  down  to  the  bone  half  an  inch  in 
front  of  the  lower  extremity  of  the  tibia.  Open 
the  joint  in  front,  divide  the  lateral  ligaments 
(Fig.  599),  expose  the  upper  surface  of  the  os  cal- 
cis, draw  back  the  detached  portion  of  the  heel 
flap,  and  with  a  narrow  saw  divide  this  bone 
obliquely  downward  and  forward  parallel  with 
and  a  little  posterior  to  the  line  of  the  plantar  in- 
cision. Eaise  the  anterior  flap,  dissect  up  the  tissues  around  the  lower  ends 
of  the  bones,  and  saw  through  the  lower  extremities  of  the  tibia  and  fibula, 
from  just  above  their  articular  surfaces  in  front  to  a  point  half  an  inch 
above  the  articular  surface  of  the  tibia  posteriorly.  Cut  otf  the  divided 
tendons  on  a  level  with  the  wound. 

The  cut  surface. of  the  os  calcis  is  then  brought  forward  and  placed  in 
contact  with  that  of  the  tibia,  the  wound  united  and  dressed  antiseptically. 
The  Eeinarls. — If  the  posterior  border  of  the  os  cal- 
cis be  cut  too  thick,  the  divided  bone  surfaces  can  not  be 
properly  apposed  without  force,  which  will  cause  the 
fragment  to  tilt  backward.  The  tilting  can  be  remedied 
by  removing  more  bone  from  the  posterior  border  or  by 
dividing  the  tendo  Achillis.  Wlienever  this  tendon  in- 
clines to  tilt  the  bone,  it  should  be  divided.  The  bone 
fragment  can  be  united  to  the  tibia  by  silver  wire,  thus 
retaining  the  sawed  surfaces  firmly  in  apposition.  The 
os  calcis  is  sawed  at  different  angles  by  different  operators 
(Fig.  596),  but  the  one  just  considered  has  given  the  most 
satisfactory  results.  Fig.  600  shows  the  appearance  of 
the  stump  after  Pirogoff's  operation. 

The  bone  in  the  flap  may  become  displaced  by  the  mus- 
cles of  the  calf,  may  necrose,  or  fail  to  unite.     The  latter 
contingencies  are  referable  especially  to  elderly  subjects. 
The  Results. — The  death  rate  from  this  operation  is 
about  ten  per  cent  by  old  methods. 

The    Modifieations    of   Pirogoff's    Operation. — These 
modifications  are  not  a  few  and  are  of  fanciful  utility  in  some  instances. 
Fergusson's  Modification. — This  modification  consists  in  retaining  the 


Fig.  600.— Appear 
ance  of  stump. 


514 


OPERATIVE  SURGERY. 


malleoli,  unless  diseased,  and  placing  the  sawed  end  of  the  os  calcis  be- 
tween them  after  having  divided  the  tendo  Achillis.  Turnipseed  and 
others  practiced  this  modification  and  advised  it.  We  are  not  disposed  to 
commend  it. 

Le  Fort's  Modification. — In  Le  Fort's  modification  the  incisions  for  the 
flaps  are  quite  similar  to  those  of  Syme's  amputation.  The  ankle  joint  is  ex- 
posed by  raising  the  dorsal  flap,  keeping  close  to  the 
bone  so  as  not  to  injure  the  anterior  tibial  artery. 
Divide  the  external  lateral  ligament  and  the  liga- 
ments between  the  astragalus  and  os  calcis.  Turn 
the  foot  inward,  and  remove  the  anterior  portion 
of  the  foot  at  the  medio-tarsal  joint.     Seize  the  as- 


FiG.  601. — Sawn  bones  in  Le  Fort's  modification. 


Fig.  603. — Appearance  of  stump. 


tragalus  with  strong  forceps,  make  tense  and  cut  the  ligaments  connecting  it 
with  the  bones  above,  and  then  remove  it.  Push  down  the  os  calcis,  and  with 
a  narrow  saw  remove  its  upper  third  horizontally  from  behind  forward,  be- 
ginning just  above  the  insertion  of  the  tendo  Achillis.    Saw  off  the  malleoli 


Fig.  603. — Sawn  bones  in  Bruns's  modi- 
fication. 


Fig.  604. — Esmareh's  modification. 
Outer  incision. 


and  the  articular  surface  of  the  tibia  also  horizontally  (Fig.  601) ;  place  the 
sawed  surfaces  in  apposition,  and  dress  in  the  usual  manner.  This  modifica- 
tion permits  the  preserved  fragment  of  the  os  calcis,  when  placed  in  position, 
to  maintain  the  same  axis  relative  to  the  end  of  the  stump  that  it  held  in  the 
foot;   consequently,   the   direct   pressure   is   received   upon   integumentary 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


516 


covering  already  adapted  to  tliat  purpose  (Fig.  G02).  It  also  provides  a 
broader  support,  and  for  these  reasons  is  regarded  by  some  as  superior  to 
the  Piroffoff  method. 


-Plantar  incision 


Fig.  606. — Inner  incision. 


Fig.  607. — Dorsal  incision. 


Bruns  recommended  that  the  sawed  surface  of  the  os  calcis  be  made  con- 
cave and  that  of  the  tibia  convex  (Fig.  603). 

Esmarch's  modification  of  Le  Fort's  operation  consists  of  making  two 
incisions :  one  across  the  sole,  the  other  across  the  dorsum  of  the  foot.  The 
former  commences  about  four  fifths  of  an  inch  below  the  tip  of  the  external 
malleolus,  and  passing  forward  (Fig.  604),  runs  under  the  cuboid  and  scaph- 
oid bones  (Fig.  605),  ending  at  the  inner  side,  one  inch  below  and  just  in 
front  of  the  internal  malle- 
olus (Fig.  606).  The  curved 
dorsal  incision  (Fig.  607), 
with  its  convexity  forward  to 
the  tuberosity  of  the  scaphoid, 
connects  the  extremes  of  the 
plantar  one.  Dissect  up  the 
dorsal  flap  to  the  tibio-tarsal 
joint,  open  the  joint,  depress 

the  foot,  expose  the  upper  surface  of  the  os  calcis  sufficiently  to  apply  a 
small  saw  behind  the  upper  margin  of  its  posterior  surface,  and  saw  the 
bone  as  before  described. 

The  Results. — Grouping  the  methods  of  Syme,  Pirogoff,  and  the  modi- 
fications, 544  amputations  at  this  situation  shows :  340  cases  before  asepsis, 
with  a  mortality  of  eighteen  per  cent;  204  done  aseptically,  with  2.95  per 
cent  fatality. 

AMPUTATIONS  AT  THE  LEG. 

Amputation  at  the  leg  is  of  great  importance,  as  it  directly  involves  the 
comfort  and  usefulness  of  the  patient.  The  unequal  arrangement  of  tissues 
and  the  necessity  of  providing  a  bearing  surface  suitable  to  meet  the  de- 
mands of  the  burdens  and  pleasures  of  life,  add  emphasis  to  the  importance 
of  considering  the  occupation  of  the  individual  in  amputation  here.  How- 
ever, the  local  arrangement  of  tissues  has  not  all  to  do  with  the  outcome  of 
amputation,  for  while  a  badly  constructed  stump  is  a  serious  affliction, 
yet  if  to  this  be  added  the  local  effects  of  intemperance  and  of  inattention 
to  the  part,  the  full  measure  of  physical  disaster  in  this  regard  is  realized. 


516 


OPERATIVE  SURGERY. 


Amputation  of  the  Leg  at  the  Lower  Third. — At  this  situation  the  crest 
of  the  tibia  and  the  interosseous  space  are  reduced  to  a  minimum,  and  ten- 
dons predominate  throughout  nearly  the  entire  location.  The  following 
methods  of  amputation  will  be  considered : 

Guyons  method,  Duval's  method,  the  Author's  method,  Teale's  method, 
the  large  posterior-flap  method,  the  dilateral-flap  method,  and  the  hood-flap 
method. 

The  Amputation  hy  Guyons  Method  (supramalleolar). — In  Guyon's 
amputation  two  incisions  are  made,  one  at  either  side  of  the  foot,  each  be- 
ginning in  front  at  the  center  of  the  ankle  joint,  and  passing  downward  and 
backward  in  a  curved  direction  just  anterior  to  the  respective  malleoli  and 
terminating  at  the  summit  of  the  curve  of  the  heel  (Fig.  608,  o).  The  heel 
flap  is  dissected  upward,  carefully  avoiding  the  posterior  tibial  vessels,  the 
tendo  Achillis  severed,  and  the  bones  of  the  leg 
are  exposed  for  two  inches  above  the  tips  of  the 
malleoli  (a'),  and  then  sawed  horizontally  at  that 
situation.  This  method  properly  locates  the  cica- 
trix and  provides  good  tissue  for  the  flap.  Drain- 
age, however,  is  faulty  unless  a  small  slit  be  made 
in  the  flap  posteriorly,  or  the  limb  be  so  placed  as 
to  facilitate  the  escape  of  the  discharges. 

The  Amputation  hy Duval's  ilfgi/iof? (supramal- 
leolar).— In  Duval's  amputation  the  place  at  which 
the  bones  are  to  be  sawed  is  higher  than  in  the 
preceding;  the  point  of  amputation  is  first  deter- 
mined in  order  to  estimate  properly  the  outline  of 
an  elliptical  incision  in  forming  the  flap  to  cover 
the  end  of  the  stump.  The  posterior  extremity 
of  the  ellipse  is  located  at  a  point  below  the  place 
of  sawing,  a  distance  equal  to  one  and  a  half  times 
the  antero-posterior  diameter  of  the  limb  at  the 

h.  DuyaUs  supramalleolar  gite  of  proposed  section  (&'),  and  the  anterior  ex- 

amputation.    o.bawline    ,         .,    ^    „^,,        „.  ,  •    j_  i    i         ia 

of  same.  tremity  ol  the  ellipse,  at  a  point  below  the  same 

place,  a  distance  equal  to  three  fourths  of  the  same 
diameter.  This  incision  crosses  the  leg  laterally  at  an  angle  of  about  45° 
(Fig.  608,  &).  The  skin  is  reflected  upward  carefully  to  just  above  the  line 
of  proposed  bone  division,  the  bones  are  sawed  horizontally,  and  the  borders 
of  the  ellipse  united  antero-posteriorly  with  sutures.  The  tendo  Achillis 
is  cut  near  its  insertion.  It  is  advised  by  some  that  its  extremity  be  united 
by  deep  sutures  to  the  extremities  of  the  tendons  in  front.  This  operation 
places  the  cicatrix  nearer  the  end  of  the  stump  and  provides  a  flap  less  in- 
clined to  friction  than  does  the  former  method. 

Amputation  by  the  Author's  Method. — This  method  comprises  the  making 
of  a  circular  integumentary  flap  provided  anteriorly  with  an  attached  peri- 
osteal lining.  If  the  site  of  operation  can  be  chosen  it  should  be  about  three 
or  three  and  a  half  inches  above  the  lower  extremity  of  the  tibia,  or,  more 
definitely  speaking,  just  below  the  point  where  the  tapering  of  the  limb 


Fig.  608.— a.  Guyon's  su- 
pramalleolar amputation, 
a'.    Saw    line    of    same. 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


517 


ceases.     The  length  of  the  flap  should  exceed  by  one  inch  a  fourth  of  the 
circumference  of  the  limb  at  the  proposed  point  of  bone  section. 

The  Operation. — Lay  out  the  flap  as  just  indicated ;  make  a  circular 
incision  through  the  integument  and  subcutaneous  tissue  down  to  the  fascia 
of  the  muscles  and  the  subcutaneous  surface  of  the  tibia.  Dissect  the  sleeve 
upward  for  about  an  inch,  then  divide  the  periosteum  at  the  subcutaneous 
surface  of  the  tibia  by  a  transverse  incision  at  the  level  of  reflection  of  the 
flap ;  also  divide  it  longitudinally  at  the  outer  and  inner  borders  of  the  sub- 
cutaneous surface  of  the  tibia  a  sufficient  distance — half  an  inch — to  allow 
the  periosteum  to  be  reflected  upward  while  attached  to  the  inner  surface  of 
the  flap.  These  longitudinal  incisions  are  increased  as  often  as  it  becomes 
necessary  to  detach  the  periosteum  to  keep  pace  with  the  turning  up  of  the 

remaining  part  of  the  flap — that  is,  instead 
of  turning  up  from  the  subcutaneous  sur- 
face of  the  tibia  an  integumentary  flap  only, 
the  periosteum  of  this  surface  is  detached 
from  a  proper  area  of  the  bone  up  to  the 


Line  indicating  oblique 
coaptation  of  flaps. 

j  Line  indicating  direction  of  sub- 

cutaneous surface  of  tibia. 


Line  indicating  anteroposterior 
coaptation  of  flaps. 

Fig.  609. — Reflection  of  the  periosteum. 


Fig.  610. — Oblique  coaptation  scar. 


saw  line,  being  raised  along  with,  and  not  separated  from,  the  integument 
which  overlies  it,  thus  forming  a  limited  lining  of  the  flap.  Fig.  609  shows 
the  extent  of  the  reflection  of  the  periosteum  from  the  tibia,  the  other  soft 
parts  having  been  removed.  After  circular  division  of  the  muscles  half  an 
inch  below  the  reflection  of  the  flap,  the  tibia  is  sawed  through  at  the  highest 
point  of  periosteal  reflection,  the  fibula  is  exposed  one  fourth  of  an  inch 
higher  up  and  divided  by  sawing  toward  the  tibia.  The  flaps  are  united 
obliquety,  parallel  with  the  margin  of  the  subcutaneous  surface  of  the  tibia,  so 
that  the  line  of  union  falls  between  the  bones,  and  the  periosteal  lining  of  the 
flap  falls  and  lies  smoothly  across  the  extremity  of  the  tibia  (Fig.  610).  It 
will  be  necessary  in  order  to  reflect  the  sleeve  flap  that  it  be  divided  longitu- 
dinally at  a  point  that  will  be  lowermost  when  the  flaps  are  obliquely  joined. 
The  Remarks. — The  limb  should  be  dressed  carefully,  cautiously  main- 
taining the  oblique  direction  of  the  flaps  till  the  healing  process  is  complete. 
The  periosteal  flap  grows  to  the  end  of  the  tibia,  lessening  the  liability  of 


518 


OPERATIVE  SURGERY. 


Periosteum  on 
subcutaneous 
surface  of  tibia 


Tibia. 


atrophy  of  the  bone  and  likewise  obviating  the  adhesion  of  the  cicatrix  to 
the  end  of  the  tibia.  Fig.  611  shows  a  vertical  section  through  the  flap 
made  three  months  after  operation  by  the  writer. 

The  Results. — Of  the  fifteen  cases  performed  by  the  writer  all  but  one 
have  resulted  in  exceptionally  serviceable  .stumps.  In  no  instance  has  bony 
spicule  appeared. 

The  Amputation  hy  TeaWs  Method. — Teale's  amputation  has  not  been 
practiced  to  any  extent  in  this  country.  The  details  of  the  method  are 
comparatively  intricate,  and  the  high  .division  of  the  bones  often  cause  an 
unwise  sacrifice  of  leverage,  especially  important  in  connection  with  modern 
prosthetic  appliance.  However,  if  the  method  be  employed,  the  lower 
third  of  the  leg  affords  the  best  site,  as  there  the  long  flap  can  be  extended 
well  downward.     The  flaps  are  rectangular,  and  should  be  carefully  marked 

out  before  the  incisions  are 
made.  The  length  of  the 
anterior  flap  is  one  half  the 
circumference  of  the  limb 
at  the  point  of  amputation, 
and  the  posterior  one  eighth. 
The  anterior  flap  is  made  by 
two  lateral  incisions  going 
down  to  the  bone,  supple- 
mented by  a  short  transverse 
one  at  the  lower  margin  of 
the  flap.  The  posterior  flap 
is  made  by  a  vigorous  cut 
down  to  the  bone.  The 
anterior  includes  all  of  the 
tissues  in  front,  and  the  pos- 
terior all  of  those  behind  the 
bones.  The  bones  are  sawed 
through  in  the  usual  man- 
ner, and  the  stump  is  care- 
fully dressed.  Although  a 
good  cushion  is  provided  at  the  end  of  the  stump  and  the  cicatrix  is  re- 
moved from  direct  pressure,  still,  the  stump  is  not  a  more  serviceable  one 
than  can  be  secured  by  more  conservative  methods. 

The  Amputation  hy  the  Large  Posterior- flap  Method. — In  this  method 
the  length  of  the  posterior  flap  is  made  to  exceed  one  half  the  circumfer- 
ence of  the  limb  at  the  proposed  point  of  bone  section,  and  the  anterior  is  a 
little  more  than  one  eighth  of  the  same  circumference.  The  posterior  flap 
is  limited  by  an  outer  and  an  inner  incision  caiTied  through  the  integument 
and  fascia  from  the  saw  line  to  near  the  insertion  of  the  tendo  Achillis 
(Fig.  613,  a).  The  inner  one  passes  in  front  of  the  inner  border  of  the 
tibia;  the  outer  passes  behind  the  fibula;  they  join  together  in  a  curved 
manner  near  the  insertion  of  the  tendo  Achillis.  The  muscles  at  the  outer 
and  posterior  surfaces  of  the  tibia  are  then  disconnected  from  that  bone,  by 


Cicatrix. 


Fig.  611. 


-Dissected  specimen  showing  the  relation 
of  parts. 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


519 


cutting  and  blunt  dissection  for  a  distance  of  two  inches.  The  soft  parts  at 
the  back  of  the  limb  are  now  grasped  by  thrusting  the  thuml)  and  finger 
into  the  gaps  caused  by  the  separation,  and  the  posterior  flap  is  completed 
by  cutting  from  without  inward  (Fig.  613).  During  the  division  of  the 
muscles  the  foot  should  be  somewhat  flexed.  The  anterior  flap  is  now  made 
down  to  the  bone  and  dissected  up,  the  interosseous  membrane  is  divided, 
retractors  are  adjusted,  bones  sawed,  and  the  posterior  tibial  nerve  is  divided 

to  above  the  point  of  bone  section.  The  muscu- 
lar structures  of  the  respective  surfaces  of  the 
limb  can  be  joined  with  deep  sutures. 

The  Amputation  by  the  Bilateral-flap  Method. 
— The  bilateral-flap  method  (Fig.  617,  a)  con- 
sists of  equilateral  flaps  constructed  from  the 
integument  and  subcutaneous  tissue  at  the  outer 


Fig.  613.  Fig.  613. 

Fig.  612. — a.  Amputation,  lower  third,  large  posterior  flap.     b.  Amputation,  upper  third, 

large  external  flap.     c.  Garden's  amputation,    d.  Lister's  modification. 

Fig.  613. — Making  large  posterior  flap. 

and  inner  surfaces  of  the  limb.  The  operation  may  be  performed  in  this 
method  with  or  without  the  periosteal  lining.  The  circular  method,  with 
oblique  coaptation,  is  far  the  better  if  the  periosteum  be  raised,  since  in 
antero-posterior  coaptation  the  periosteal  flap  is  tilted,  and  is  more  liable  to 
eversion  and  the  production  of  liony  spicular  growths. 

The  length  of  the  bilateral  flaps  is  estimated  in  the  usual  manner.  There- 
fore, the  width  of  each  flap  at  the  base  is  equal  to  half,  and  the  length  is 
in  excess  of  one  fourth  the  circumference.  Each  one  is  nearly  semicircular, 
and  the  points  of  junction  should  be  at  the  center  of  the  limb,  anteriorly 


520  OPERATIVE  SURGERY. 

and  posteriorly,  thus  bringing  the  anterior  point  of  union  to  the  inner  side  of 
the  crest  of  tlie  tibia  ;  it  should  also  be  well  below  the  point  of  the  proposed 
section  of  the  tibia.  The  posteriar  point  of  junction  is  considerably  above 
that  of  the  anterior,  to  provide  for  suitable  drainage.  After  having  been 
properly  outlined,  each  flap  is  dissected  upward  to  near  the  point  of 
bone  division ;  the  muscles  are  divided  by  a  circular  incision,  then  pushed 
upward  above  the  anterior  point  of  union  of  the  flaps,  and  the  tibia  is 
sawed  off  on  a  line  corresponding  to  the  junction  of  the  flaps  posteriorly. 
The  fibula  is  sawed  a  fourth  of  an  inch  the  shorter.  If  there  be  an  un- 
due amount  of  muscular  tissue  behind,  it  can  be  trimmed  off  until  it  admits 
of  the  ready  union  of  the  borders  of  the  flaps.  Suitable  drainage,  antero- 
posterior coaptation,  and  an  antiseptic  dressing  comprise  the  immediate 
attentions  in  the  case. 

The  amputation  hy  the  hood-flap  method  is  a  modification  of  the  circular, 
the  skin  cuff  being  slit  up  posteriorly  to  the  point  at  which  the  bone  is 
to  be  divided,  and  the  corners  trimmed  off  to  resemble  the  outlines  of  the 
lower  portions  of  the  bilateral  flaps.  This  flap  is  then  reflected  upward, 
and  the  muscles  and  bones  divided  as  before.  The  line  of  coaptation  is 
antero-posterior  (Fig.  617,  a). 

The  advantages  claimed  for  this  method  are :  perfect  drainage ;  the  loca- 
tion of  the  cicatrix  on  the  posterior  surface  of  the  stump ;  and  the  falling  of 
the  integument  over  the  end  of  the  bone,  thus  obviating  the  presence  of  a 
cicatrix  at  that  point.  Like  the  bilateral,  it  can  be  employed  in  connec- 
tion with  the  periosteal  flap;  still,  as  it  is  joined  to  form  an  antero-posterior 
line  of  union,  it  is  open  to  the  same  objections  as  the  bilateral  with  refer- 
ence to  the  proper  application  to  the  bone  of  the  periosteum. 

The  Results. — Of  2,343  cases  of  amputation  at  the  lower  third  of  the 
leg,  1,909  were  done  before  asepsis,  with  a  mortality  of  24.6  per  cent,  and 
434  were  done  under  asepsis,  of  which  11.6  per  cent  died. 

Amputation  of  the  Leg  at  the  Middle  Third. — The  limb  can  be  ampu- 
tated at  this  part  by  the  methods  employed  at  the  lower  third,  and  the 
principles  applicable  to  the  lower  third  have  an  equal  force  at  this  situ- 
ation. The  presence  of  the  calf  offers  an  additional  difficulty  in  obtaining 
the  oblique  coaptation,  but  does  not  interpose  an  insurmountable  obstacle  to 
it.  Care  in  dressing  the  stump  will  maintain  the  obliquity  of  the  line  of 
coaptation  in  the  periosteal-flap  method.  The  bilateral-  (Fig.  617)  and 
hood-flap  methods,  either  with  or  without  the  periosteal  lining,  present  to 
the  surgeon  the  means  of  making  a  serviceable  stump.  Amputation  here 
can  also  be  performed  by  either  the  large  posterior-  or  the  large  external- 
flap  method. 

The  Amputation  hy  the  Large  Posterior-flap  Method  (Hey). — In  this 
method  first  ascertain  the  circumference  of  the  limb  at  the  point  of  pro- 
posed amputation;  then  mark  off  two  U-shaped  flaps,  posterior  and  ante- 
rior, the  base  and  length  of  the  former  equaling  one  half  the  circum- 
ference of  the  limb,  and  the  length  of  the  latter  one  sixth.  The  leg  is  flexed 
on  the  thigh,  and  the  skin  and  subcutaneous  tissues  are  divided  with  a  scalpel 
along  the  line  of  the  posterior  flap  as  indicated.     Flex  the  foot  and  divide 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


521 


the  gastrocnemius  in  the  line  of  the  incision ;  separate  the  remaining  soft 
parts  at  this  situation  from  the  posterior  surfaces  of  the  bones,  grasp  them 
with  the  thumb  and  fingers  and  sever  them  from  within  outward  with  a 
sharp  transverse  cut ;  separate  further  the  soft  structures  from  the  bones  up 
to  the  saw  line ;  make  the  anterior  flap  by  dividing  first  the  integument  and 
subcutaneous  tissue,  and  then  severing  the  muscles  down  to  the  bone  and 
displacing  them  upward  to  the  saw  line  in  front ;  divide  the  interosseous 
membrane  ;  apply  the  three-tailed  retractor  and  saw  the  bones  transversely. 
The  triangular  projection  of  the  crest  of  the  tibia  is  then  removed  to  prevent 
its  impingement  on  the  anterior  flap. 

Lee  practiced  amputation  at  this  part  of  the  limb  after  the  method  of 
Teale,  except  the  long  flap  was  placed  posteriorly,  and  only  the  muscles  of 
the  calf  were  included  in  it.  Both  flaps  were  reflected  upward  to  the  point 
of  bone  section,  the  remaining  soft  parts  were  divided  transversely,  the  re- 
tractor was  adjusted,  and  bones  sawed  through  as  before.  Both  methods 
provide  serviceable  stumps ;  the  latter  is  more  easily  performed,  but  requires 
higher  division  of  the  bones  than  the  former  method.  In  neither  method  is 
good  drainage  provided. 

The  long  external-flap  method,  having  a  semicircular  incision  on  the 
inner  side,  offers  good  drainage,  and  carries  the  cicatrix  beyond  the  point 
of  pressure.  These  flaps  may  be  either  integumentary  or  muscular  ;  the 
latter  are  made  by  transfixion  or  the  reverse ;  the  former  by  external  incision 
with  the  ordinary  scalpel,  and  circular  section 
of  the  muscles  with  the  long  knife.  The  prin- 
ciples controlling  the  length  of  the  flaps  are 
the  same  as  previously  stated  for  single  flaps. 
The  long  flap  should  be  made  from  the  outer 
side  of  the  leg,  having  a  base  equal  to  one  half 
the  circumference  of  the  limb.  The  inner  or 
short  flap  is  semicircular  in  outline  (Fig. 
614).  The  bones  are  sawed  off  just  above 
the  anterior  point  of  junction  of  the  flaps, 
united,  and  the  wound  is  dressed  as  before. 

The  Results. — Of  1,967  cases,  1,751  before 
asepsis  had  a  mortality  of  27.8  per  cent;  of 
217  under  asepsis,  11.2  per  cent  died. 

Amputation  of  the  Leg  at  the  Upper  Third. 
— Amputation   at    the    upper    third    involves 

much  more  tissue  than  at  either  of  the  preceding  parts  of  the  limb.  Either 
variety  of  flap  employed  at  the  middle  third  can  be  utilized  at  the  upper, 
but  modifications  of  procedure  are  advisable  on  account  of  the  difference  in 
the  bulk  and  relation  of  the  tissues  at  the  upper  third. 

The  Amputation  hy  a  Large  External  Flap  (Farabeuf). — The  flap  is 
U-shaped,  and  the  length  is  equal  to  one  third  the  circumference  of  the 
limb  at  the  point  of  bone  section.  It  is  marked  out  carefully  before 
division,  beginning  in  front  at  the  level  of  the  proposed  bone  section,  and 
passing  downward  the  proper  distance  along  the  inner  border  of  the  crest 
35 


Fig.  614.- 


-Long  external-flap 
method. 


522 


OPERATIVE  SURGERY. 


of  the  tibia,  is  carried  in  a  curved  direction  across  tlie  outer  aspect  of  the 
limb,  and  then  upward  in  a  line  diametrically  opposite  the  anterior  incision 
to  a  point  about  an  inch  and  a  half  below  the  level  of  the  primary  point  of 
departure  (Fig.  617,  &).     Flex  the  leg  and  divide  the  skin  and  subcutaneous 


Fig.  615.— Making  the  flap. 


tissue  throughout  the  entire  course  of  the  flap  with  a  scalpel.  Then  divide 
the  muscles  obliquely  from  above  downward  and  outward  down  to  the  bone 
and  interosseous  membrane  (Fig.  615) ;  separate  them  upward  carefully  to 
the  point  of  bone  section,  cautiously  avoiding  injury  of  the  anterior  tibial 
artery  as  it  appears  in  front  of  the  interosseous  membrane.  The  tissues 
at  the  inner  side  are  divided  transversely  down  to  the  bone  by  transfixion 
or  otherwise,  and  separated  from  the  bone  up  to  the  line  of  section.     The 

periosteum  of  the  tibia  is  divided  an  inch 
below  the  line  of  proposed  section  by 
a  circular  incision,  then  at  each  side  of 
the  bone  by  a  short  vertical  one;  the  an- 
terior and  posterior  flaps  thus  formed  are 
pushed  upward  by  the  elevator  to  above 
the  saw  line;  the  interosseous  membrane 
is  divided,  the  retractor  adjusted,  and  the 
bones  are  sawed  in  the  following  manner : 
Divide  the  fibula  obliquely  from  above 
downward  and  inward,  about  a  quarter  of 
an  inch  shorter  than  the  tibia;  saw  the 
tibia  across  and  remove  the  sharp  projec- 
tion at  the  anterior  border  -^vith  a  mallet 
and  chisel  (Fig.  616) ;  adjust  the  perios- 
teal flaps,  sew  them  in  place  with  catgut, 
and  unite  the  flaps  in  the  usual  manner. 
It  is  much  better  to  strip  off  the  peri- 
osteum without  disturbing  the  superim- 
posed tissue,  as  thus  its  vitality  is  better 
preserved.     Treves  regards  this  method  with  great  favor. 

The  Amputation  hy  the  Circular-flap  Method. — In  the  circular  method 


Pig.  616.— Flap  formed  and  crest  of 
tibia  sawed. 


AMPUTATION   AT   THE   LOWER   EXTREMITY.  523 

the  length  oJ'  the  outl'  is  made  nearly  one  hall'  the  eireumferencc  of  thi'  limb 
at  the  point  of  bone  section. 

The  flap  is  made  hy  a  circular  sweep  of  the  knife.  As  the  posterior 
part  retracts  considerably,  the  anterior  is  dissected  up  until  it  retracts  an 
equal  amount,  after  which  the  gastrocnemius  is  seized  and  cut  off  on  a  line 
with  the  reflection  of  the  integument.  The  integumentary  cuff  is  carried 
up  (the  gastrocnemius  accompanying  the  posterior  part)  nearly  to  the  line 
of  bone  section.  The  remaining  soft  parts  are  divided  transversely  down  to 
the  bone  a  little  below  the  saw  line,  the  retractor  is  applied,  and  the  bones 
are  sawed  as  in  the  preceding  method.  The  periosteum  and  the  projection 
of  the  bony  crest  are  also  treated  as  in  the  preceding  instance.  Direct 
pressure  is  not  well  borne  at  the  end  of  this  stump,  but  when  flexed  it  is 
very  serviceable. 

The  Amputation  hy  the  Bilateral-flap  Method  (Fig.  617,  6). — This 
method  has  been  described  already  in  amputation  of  the  lower  third  of  the 
leg.  At  the  upper  third  the  flaps  should  each  equal  in  length  one  third  of 
the  circumference  of  the  limb  at  the  seat  of  amputation.  In  other  respects 
no  substantial  difference  in  the  procedure  obtains.    The  Inlateral-flap  method 


Fig.  617. —Bilateral-flap  method,  sometimes  called  hood-flap  method. 


is  regarded  by  many  surgeons  as  one  of  the  most  useful  that  can  be  em- 
ployed.    It  is  called  sometimes  the  hood-flap  method. 

The  after-treatment  in  amputations  of  the  leg  is  substantially  similar  in 
each  instance :  the  flap  should  be  well  supported  without  undue  pressure, 
the  stump  slightly  elevated  and  comfortably  placed  on  a  pillow;  drainage 
agents  should  not  extend  into  the  wound  needlessly,  and  care  is  required  to 
maintain  the  flaps  suitably  after  removal  of  the  sutures. 

The  Results. — Of  920  amputations  at  this  situation,  614  before  asep- 
sis, 69.8  per  cent  died ;  306  under  asepsis,  39.8  per  cent  died. 

Amputation  at  the  Knee  Joint  {Disarticulation) . — The  dangerous  sequels 
that  formerly  rendered  amputation  at  this  joint  a  much-dreaded  procedure 
are  now  eliminated,  or  so  modified  by  modern  antiseptic  technique  as  to 
place  it  high  in  the  list  of  amputations  near  to  this  point,  as  a  conservative 
measure  of  undoubted  good  repute.  Not  only  is  the  rate  of  mortality  com- 
paratively low,  but  its  worth  as  a  serviceable  pressure-bearing  stump  is  of 
the  highest  order.  The  makers  of  prosthetic  appliances  are  unreserved  in 
their  expressions  of  approval  of  the  latter  fact.  The  condyles  of  the  femur 
not  only  offer  a  broad  bearing  surface,  but  also  serve  an  important  purpose 


524  OPERATIVE  StTRaERY. 

in  retaining  the  artificial  appliance  in  good  position,  because  of  the  excellent 
grasp  they  furnish  the  instrument  at  the  thigh. 

In  this  operation  the  joint  surface  is  not  disturbed ;  the  semilunar  car- 
tilages are  left  attached  to  the  femur,  thus  reducing  to  a  minimum  the 
retraction  of  the  synovial  pouch  and  the  surrounding  tissues.  The  patella 
is  not  removed  unless  it  be  diseased,  and  therefore  provides  continued  at- 
tachment for  the  quadriceps  muscle.  The  patella  presents  no  local  obstacle 
to  use  of  the  limb,  for  it  finally  rests  out  of  the  way  just  above  and  on 
a  level  with  the  condyles.  The  ligaments  should  be  cut  short,  and  the 
popliteal  artery  tied  only  after  sufficient  isolation  is  practiced  to  secure  ample 
space  for  proper  occlusion  of  the  vessel. 

The  Anatomical  Points. — The  inner  condyle  of  the  femur  is  larger  and 
more  prominent  than  the  outer,  therefore  the  inner  flap  should  be  made 
correspondingly  longer.  The  apex  of  the  patella  is  on  a  line  with  the  mar- 
gin of  the  upper  extremity  of  the  tibia.  The  synovial  membrane  proper  of 
the  joint  extends  about  an  inch  above  the  patella,  and  above  this  limit  a 
synovial  bursa  is  fouiid  beneath  the  tendon  of  the  quadriceps  and  the  lower 
portions  of  the  vasti  muscles.  The  bursa  communicates  with  the  joint  in 
about  eighty  per  cent  of  the  cases  by  an  opening  of  varying  size,  and  is 
an  important  factor  in  the  after-treatment,  since,  when  connected  with  the 
joint,  it  may  collect  and  retain  for  a  time  the  discharges  (page  417). 

Amputation  at  the  knee  joint  may  be  performed  by  the  following 
methods : 

Amputation  hy  the  hilatej^al-flap  method,  the  elliptical- incision  method, 
the  circular-incision  method,  and  hy  the  long  anterior-flap  method. 

The  Amputatiofi  by  the  Bilateral-flap  Method  (Stephen  Sniith). — This 
method  is  properly  a  hood-flap  method,  and  is,  without  doubt,  superior  to 
any  yet  devised.  It  provides  two  well-nourished  flaps,  which,  when  united, 
locate  the  cicatrix  between  the  condyles  posteriorly,  also  affording  admirable 
drainage. 

The  Operation. — With  the  thigh  elevated  and  the  leg  extended,  begin  the 

anterior  incision  of  each  flap   one  inch  below  the  tuberosity  of  the  tibia, 

^-—^  cutting  through  the  skin  and  subcutaneous 

\^         and  muscular  tissues.     Carry  the  incision  of 

„.;v ;   I  \        one  side  downward  and  forward  below  the 

y"  1;  A       I        curve  of  the  leg,  thence  inward  and  back- 

/,//  s|:         p       ,^M      I       ward  to  the  middle  of  the  under  surface  of 

^  ill    ^"        ^    ^^^m\     I      *-'^®  ^^^'  *^®^  directly  upward  to  the  middle  of 

//}     \        lj^^^m:>\     the  popliteal  space  (Figs.  617,  &,  and  633,  a). 

\     \    \       ^^^^i  ^^^^     The  opposite  flap  is  made  in  a  similar  man- 

""  V^^^^^^ai^  i^6r,  remembering,  however,  that  the  flap  at 

Fig.  618.— Appearance  of  the  flaps,    the   inner   side   must  be  made  the  longer, 

on  account  of  the  greater  length  and  size 
of  the  inner  condyle.  Eaise  the  flaps  until  the  apex  of  the  patella  and  the 
articulation  are  reached;  divide  the  ligamentum  patellae;  open  the  joint 
in  front ;  divide  the  crucial  ligaments ;  draw  the  head  of  the  tibia  forward, 
and  pass  a  long  knife  behind  it;  extend  the  leg  somewhat  and  cut  the 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


525 


remaining  tissues  directly  across.  After  removal  of  the  leg  the  flaps  present 
the  appearance  shown  in  Fig.  G18.  The  flaps  are  then  united  and  suitahle 
drainage  is  provided.  When  healed  the  stump  presents  the  appearance 
shown  in  Figs.  619  and  620. 

The  Precautions. — Before  severing  the  posterior  tissues  be  ^careful  to 
ascertain  if  perfect  control  be  had  of  the  femoral  artery.  A  perplexing 
sequel  to  this  operation,  in  rare  instances,  is  the  formation  of  an  abscess 
beneath  the  quadriceps  extensor,  due  to  the  collection  of  pus  at  the  upper 
synovial  pouch  when  connected  with  the  joint,  the  elevation  of  the  stump 
causing  the  discharges  to  gravitate  to  that  point.  This  complication  can 
be  avoided  by  the  division  of  the  lateral  synovial  bands  commanding  the 
entrance  to  the  pouch  and  the  introduction  of  a  drainage  tube  to  the  upper- 
most portion,  or  by  carrying  the  tube  through  the  uppermost  extremity  to 
the  anterior  surface  of  the  thigh.  Sometimes  compression  firmly  and  con- 
tinuously applied  over  the  pouch  will  answer  the  purpose  of  prevention. 
If  care  be  not  taken  in   the  application  of  the  dressings,  undue  pressure 


Fig.  619. — Side  view  of  stump. 


Fig.  620.- — Posterior  view  of 
stump. 


will  be  made  on  the  tissues  covering  the  condyles  of  the  femur,  causing 
ulceration  and  even  sloughing  of  the  flaps  at  these  situations. 

The  Fallacies. — The  operation  has,  however,  this  fallacy,  which  has  been 
the  cause  of  much  chagrin  to  surgeons  on  rare  occasions,  the  danger  of 
making  the  flaps  too  short,  followed  by  the  necessity  of  removing  the  pa- 
tella, or  sawing  off  the  condyles  before  the  flaps  can  be  properly  united. 
If  the  semilunar  fibro-cartilages  be  permitted  to  remain  connected  with  the 
femur  they  lessen  the  degree  of  retraction  of  the  soft  parts ;  but  they  not 
infrequently  slough  and  come  away. 

Amputation  at  the  Knee  Joint  for  Gangrene  of  the  Toes  and  Foot  due 
to  an  Atheromatous  Condition  of  the  Arteries  (Stephen  Smith). — In  rela- 
tion to  the  procedure,  Dr.  Smith  says  :  "  This  operation  was  devised  for  the 
purpose  of  securing  well-nourished  flaps  in  knee-joint  amputation  in  cases 
of  gangrene  of  the  toes  and  foot  due  to  an  atheromatous  condition  of  the 
arteries  of  the  limb.  This  result  is  obtained  by  two  incisions,  viz.  :  First, 
a  perpendicular  incision  on  the  anterior  aspect  of  the  knee,  by  which  only 
the  terminal  part  of  the  arteries  of  the  soft  tissues  of  the  joint  is  divided  ; 
and,  second,  a  circular  incision  below  the  origins  of  the  articular  arteries,  to 


526  OPERATIVE  SURGERY. 

avoid  dividing  their  trunks.  The  several  steps  of  the  operation  are  as 
follows  : 

"  Compress  the  artery  at  the  groin  with  the  four  fingers  on  a  soft  pad  to 
avoid  breaking  the  brittle  structure ;  then  make  a  straight  incision  com- 
mencing two  inches  above  the  upper  border  of  the  patella,  downward  over 
the  center  of  that  bone  to  the  lower  border  of  the  tuberosity  of  the  tibia ; 
from  the  lower  extremity  of  this  incision  make  two  incisions,  an  external 
and  an  internal  one,  both  curved  downward,  one  to  the  external  and  the 
other  to  the  internal  border  of  the  limb  ;  now  join  these  two  incisions  by  a 
straight  incision  across  the  posterior  surface  of  the  leg.  Dissect  these  flaps 
from  the  bone  upward  to  the  joint,  then  disarticulate  and  finish  by  removing 
the  patella. 

"  The  precautio7is  to  be  taken  are  to  make  the  lateral  incisions  with  a 
suflBciently  large  curve  to  insure  the  covering  of  the  long  internal  condyle  of 
the  femur  and  to  include  as  much  as  possible  of  the  recurrent  tibial  artery. 
The  haemorrhage  is  so  slight,  owing  to  the  division  of  only  the  extremities  of 
the  arteries,  that  ligatures  are  rarely  required  except  for  the  popliteal  artery 
and  the  proximal  end  of  the  recurrent  tibial  artery." 

The  Amputation  hy  the  Elliptical-incisioji  Method  (Baudens). — In  this 
method  an  elliptical  incision  is  made  around  the  upper  portion  of  the  leg 
at  an  angle  of  30°  with  its  long  axis.  The  anterior  and  lower  end  of  the 
ellipse  is  located  on  the  tibia  at  a  point  below  the  apex  of  the  patella  equal  to 
the  antero-posterior  diameter  of  the  limb,  and  the  upper  and  posterior  ex- 
tremity of  the  ellipse  is  placed  at  half  this  distance  below  the  level  of  the 
apex  of  the  patella.  The  integument  is  reflected  up  on  a  line  with  the  apex 
of  the  patella,  leg  flexed,  ligamentum  patellae  divided,  the  blade  passed 
between  the  head  of  the  tibia  and  the  semilunar  cartilages,  the  soft  parts 
at  the  back  of  the  joint  are  cut  across,  and  the  limb  is  removed. 

The  Amputation  hy  the  Circular-flap  Method. — Extend  the  leg  and  make 
a  circular  incision  around  it,  about  four  inches  below  the  patella,  through 


Fig.  621. — Amputation  by  circular  method. 

the  integument  and  subcutaneous  tissues.  Dissect  up  the  flap  to  a  line  cor- 
responding to  the  apex  of  the  patella;  flex  the  leg  and  divide  the  liga- 
mentum patellae  at  the  apex  of  the  bone ;  open  the  joint  in  front,  and 
divide  the  lateral  ligaments  close  to  the  tibia  so   that  the  semilunar  car- 


AMPUTATION   AT   THE   LOWER   EXTREMITY. 


527 


tilages  will  remain  connected  with  the  femur.     Flex  the  leg  and  cut  the 
crucial  ligaments.     Pass  a  long  knife  between  the  bones,  extend  the  leg, 


Pig.  633. — Antero-posterior  coaptation. 


Fig.  633. — Transverse  coaptation. 


and  sever  the  posterior  connections  as  before  (Fig.  631).     The  flaps  can 
be  united  from  before  backward  (Fig.  632),  or  transversely  (Fig.  623),  the 

former     being     the     better  

method,  for  obvious  reasons. 
If  difficulty  be  experienced 
in  dissecting  up  the  flap,  a 
slit  of  accommodation  may 
be  made  at  the  side  (Fig. 
621). 

The  Amputation  hy  the 
Long  Anterior-  and  Short 
Posterior-flap  Method  (Pol- 
lock).— Flex  the  leg  and 
make  a  long  semicircular- 
shaped  flap,  beginning  a 
little  below  the  center  of  the 
inner  surface  of  the  internal 
condyle,  extending  down- 
ward to  five  inches  below 
the  patella,  then  around  in 
front  and  upward  to  a  point 

on  the  external  condyle  similar  to  that  of  starting  (Fig.  624).    Dissect  the 
flap  upward  to  the  patella,  open  the  joint  as  before ;  divide  the  lateral  and 

crucial  ligaments;  draw  the  head  of 


the  tibia  forward  and  pass  a 
knife  behind  it,  making  a  short  pos- 
terior flap  from  above  downward,  be- 
ginning the  incision  at  the  upper 
limits  of  the  anterior  flap.  When 
united  the  cicatrix  is  well  protected 
and  good  drainage  afi'orded  (Fig.  635). 
The  Results. — A  careful  examina- 
tion shows  the  fact  that  of  690  cases 
of  disarticulation  at  the  knee  joint  for  all  causes,  421  were  done  before  asep- 
sis, with  a  mortality  of  32.8  per  cent,  and  369  under  asepsis,  14.6  per  cent 


Fig.  634.— Outlines  of  flaps. 


long 


Fig.  635. — Appearance  of  stump. 


528 


OPERATIVE  SURGERY. 


died.  .  Ampvitation  througli  the  knee  joint  offers,  as  a  rule,  a  better  chance 
for  life  than  through  the  upper  third  of  the  leg.  The  long  anterior  flap 
covers  the  condyles  less  suitably,  and  is  prone  to  slough.  The  long 
posterior  flap  has  nothing  to  commend  it  when  either  of  the  preceding  meth- 
ods is  available. 

Amputation  of  the  Thigh  through  the  Condyles. — Amputation  through 
the  condyles  offers  no  mechanical  advantage  over  that  made  through  the 
articulation.  The  rate  of  mortality  is,  according  to  some  authorities,  some- 
what greater  in  the  former,  being  reported  at  about  forty-eight  per  cent, 

although  this  would,  without  doubt,  be  much 
lessened  by  the  employment  of  rigid  antisep- 
tic measures.  The  usefulness  of  the  stump  is 
decidedly  in  favor  of  the  latter  method. 
However,  as  conditions  sometimes  arise  ren- 
dering the  disarticulation  or  excision  im- 
practicable, amputation  through  the  condyles 
becomes  a  valuable  expedient. 

The  Amputation  hy  Gardens  Method. — 
Extend  the  leg,  seize  the  joint  with  the  left 
hand,  the  ends  of  the  thumb  and  index  finger 
resting  as  nearly  as  possible  over  the  centers 
of  the  condyles.  With  a  stout  scalpel  make 
an  anterior  semilunar  flap,  commencing  at 
the  point  indicated  by  the  end  of  the  index 
finger,  and  passing  around  in  front  about  two 
inches  below  the  patella  to  the  tip  of  the 
thumb  on  the  opposite  side.  If  the  question 
of  amputation  or  excision  be  undecided,  re- 
flect the  anterior  flap  first;  then,  if  the  con- 
dition of  the  parts  requires  amputation,  con- 
nect the  extremities  of  the  anterior  flap  by  a 
short  posterior  incision  carried  directly  down 
to  the  bone  (Fig.  626).  Eeflect  both  flaps 
upward  to  the  base  of  the  condyles;  flex 
the  leg  to  draw  down  the  patella,  and  divide 
the  remaining  tissues  surrounding  the  con- 
dyles down  to  the  bone;  then  saw  off  the 
condyles  at  the  base,  secure  the  vessels  as  be- 
fore described,  and  unite  the  divided  parts.  The  lower  epiphysis  joins  the 
shaft  of  the  femur  at  about  twenty  years  of  age,  therefore  in  young  subjects 
the  saw  line  should  be  made  as  far  as  possible  below  the  line  of  epiphyseal 
junction,  which  is  marked  by  the  adductor  tubercle  on  the  inner  condyle. 

The  Results. — The  rate  of  mortality  as  reported  by  Garden  was  about 
seventeen  per  cent  by  old  methods. 

Lister  and  Farabeuf  have  each  modified  Garden's  method.  Lister  made 
an  anterior  flap  by  a  transverse  incision  between  the  tuberosities  of  the  tibia 
on  a  line  with  the  tubercle  of  that  bone,  and  a  posterior  flap  at  an  angle 


Fig.  626.- 


-Outlines  of  Garden's 
method. 


AMPUTATION  AT   THE  LOWER  EXTREMITY.  529 

of  45°  with  the  long  axis  of  the  leg,  which  iiichulod  tlie  integument  and 
fat.  He  elevated  tlie  limb,  dissected  up  the  posterior  flap,  divided  the  ham- 
string tendons  as  soon  as  exposed,  raised  the  remaining  flap  tissue  in  the 
usual  manner  to  a  point  that  exposed  the  upper  border  of  the  patella  when 
the  leg  was  flexed,  divided  the  quadriceps  tendon,  exposed  the  anterior 
surface  of  the  femur  immediately  above  the  cartilage,  and  sawing  the  bone 
transversely  at  that  point,  removed  the  limb. 

Faraieufs  modification  differs  from  Lister's  only  in  the  construction  of 
the  outlines  of  the  flaps.  The  anterior  flap  exceeds  in  length  by  an  inch 
the  antero-posterior  diameter  of  the  limb  at  the  point  of  bone  section. 
The  length  of  the  posterior  flap  equals  about  half  the  diameter  of  the  limb 
at  that  point.  The  base  of  each  flap  corresponds  to  the  line  of  the  articula- 
tion, that  of  the  anterior  flap  being  limited  internally  by  a  point  two  inches 
behind  the  inner  edge  of  the  head  of  the  tibia,  externally  by  the  fibula, 
thus  exceeding  in  width  more  than  half  the  circumference  of  the  limb. 

The  Amimtation  hy  Gritti's  Method. — Gritti's  method  (Fig.  627,  a)  of 
procedure  is  osteoplaMic,  and  although  it  bristles  with  surgical  ingenuity, 
still,  the  results  of  the  method  do  not  sufficiently  emphasize  its  practical 
utility  to  establish  for  it  a  fixed  place  in  amputations  in  this  situation.  The 
special  technique  of  the  method  requires  that  the  patella  be  bisected  in  a 
plane  passing  vertically  through  its  transverse  diameter,  and  that  the  attached 
portion  of  the  bone  be  fixed  to  the  sawed  end  of  the  femur  by  silver-wire 
or  kangaroo-tendon  sutures.  A  lion-jaw  forceps  to  hold,  a  fine  keyhole  saw 
to  divide,  and  a  slender  bone  drill  to  pierce  the  patella,  are  the  special  imple- 
ments required  for  the  operation. 

An  anterior  rectangular  incision  is  made  reaching  downward  from  the 
centers  of  the  condyles  of  the  femur  to  the  tubercle  of  the  tibia  ;  the  integu- 
ment on  the  posterior  surface  is  divided  by  an  incision  directed  transversely 
or  slightly  downward,  and  connecting  the  upper  extremities  of  the  rec- 
tangular one  ;  the  ligamentum  patellae  is  severed  at  the  insertion,  the  flap 
containing  it  dissected  up,  the  synovial  membrane  removed  from  its  attach- 
ment to  the  femur  in  front,  the  bone  sawed  just  above  the  articular  carti- 
lages, and  the  remaining  soft  parts  are  divided  with  a  long  knife  carried 
directly  through  them.  The  articular  surface  of  the  patella  is  then  sawed 
off,  and  the  remaining  part  placed  in  contact  with  the  lower  end  of  the 
femur,  to  which  it  is  confined  by  silver-wire  or  kangaroo-tendon  sutures. 

The  Fallacies.— The  sawing  of  the  patella  is  always  difficult,  and  is  often 
attended  with  injury  of  the  soft  parts  unless  great  care  be  exercised.  The 
rongeur  can  be  substituted  for  the  saw  with  good  results.  Owing  to  con- 
traction of  the  quadriceps  muscle  it  may  be  difficult  to  place  the  fragment 
of  the  patella  in  proper  position,  and  also  to  retain  it  there.  If  a  tendency 
to  displacement  from  this  cause  be  apparent,  the  division  of  the  quadriceps 
tendon  at  the  base  of  the  patella  or  the  removal  of  an  additional  section  of 
bone  should  be  practiced. 

Stokes's  modification  of  Gritti's  method  consists  in  making  an  anterior 
oval  instead  of  a  rectangular  flap,  the  posterior  flap  being  made  one  third  the 
length  of  the  anterior.     The  femur  is  sawed  off  an  inch  above  the  condyles 


530 


OPERATIVE  SURGERY. 


(Fig.  627,  h)  instead  of  through  their  base.    The  cartilaginous  surface  of  the 
patella  is  scraped  off,  and  the  bone  itself  is  then  united  to  the  extremity  of 

the  femur  by  strong  catgut  or  kangaroo  ten- 
dons passed  through  the  soft  tissues  attached 
to  the  patella  and  those  immediately  behind 
the  thigh  bone. 

Stokes's  modification  (Fig.  627,  h)  dis- 
turbs the  soft  parts  but  little,  and  permits 
the  divided  surfaces  of  the  bones  to  lie  easily 
in  contact.  The  practical  results  of  this 
modification  are  superior  to  those  of  the 
original  method. 

The  Results. — Of  130  cases  of  amputa- 
tion by  Gritti's  operation  and  Stokes's  modi- 
fication done  under  asepsis,  16  cases,  or  12.3 
per  cent,  died. 

Osteoplastic  flaps,  when  applied  to  the 
ends  of  divided  bones,  appear  in  many  in- 
stances to  serve  important  purposes.  How- 
ever, if  greater  care  were  taken  in  the  mak- 
ing of  the  ordinary  simple  flaps,  there  would 
be  less  occasion  to  prompt  the  making  of 
the  complex  ones.  The  osteoplastic  variet}'', 
like  the  periosteal,  exercises  an  influence  in 
closing  and  protecting  the  medullary  canal, 
in  increasing  the  stability  of  the  end  of  the 
bone,  and  correspondingly  the  usefulness  of 
the  stump,  by  aiding  nutrition  and  provid- 
ing for  it  a  freely  movable  integumentary 
covering. 

Bier  and  Eiselsherg  carried  into  effect 
this  proposition  at  the  upper  third  of  the  leg  in  the  following  manner :  Out- 
line an  antero-internal  cutaneous  flap  whose  base  equals  half  of  the  circum- 
ference of  the  leg,  and  whose  length  equals  its  diameter.  Dissect  upward 
the  flap  thus  formed;  incise  transversely  at  the  apex  of  the  flap,  the  peri- 
osteum on  the  subcutaneous  surface  of  the  tibia,  and  also  longitudinally 
upward  from  this  part  along  the  borders  of  the  tibia  to  a  sufficient  length 
to  form  the  flap  (Fig.  628).  The  flap  should  be  shorter  for  the  tibia  than 
for  both  bones;  remove  from  the  anterior  surface  of  the  tibia  by  means  of 
a  Gigli-Haertel  saw  a  bone  flap,  leaving  attached  the  superimposed  peri- 
osteum; fracture  the  bone  flap  at  the  base  and  turn  it  upward,  the  peri- 
osteum forming  a  hinge  (Fig.  629) ;  unite  posteriorly  by  a  semicircular  in- 
cision the  upper  ends  of  the  primary  flap ;  amputate  the  limb  in  the  usual 
manner,  finally  bringing  down  and  applying  to  the  end  of  one  or  both 
bones,  as  the  case  may  be,  the  periosteal  flap  (Fig.  630),  which  is  then 
fastened  to  the  divided  end  or  ends  by  chromicized  catgut;  bring  down 
into  place  the  upper  flap  and  close  the  wound  in  the  usual  manner,  dress- 


Pie.  627. — a.  Gritti's  amputation 
b.  Stokes's  incisions. 


AMPUTATION  AT  TIIR   LOWER  EXTRE:\IITY. 


531 


ing  the  stump  quite  firmly  to  hasten  union  of  the  complex  flap,  with  over- 
lying simple  tlap.  Bier,  in  order  to  increase  the  supporting  power  at  the 
lower  end  of  the  leg,  removed  a  wedge-shaped  piece  (Fig.  631)  from  just 


Fig. 


638.— Osteoplastic  flap.    Method  of 
Bier  and  Eiselsberg. 


629. — Osteoplastic    flap   turned    up. 
Method  of  Bier  and  Eiselsberg. 


above  the  end  of  the  bone,  turned  the  lower  fragment  upward  and  united 
it  in  position,  thus  closing  the  medullary  opening,  and  changing  the  rela- 
tions of  the  scar  to  the  end  of  the  stump.  In  this  connection  we  are  dis- 
posed to  say :  that  if  greater  care  were  taken  in  making  simple  amputations 


Fig.  630. — Osteojilastic  flap  turned  down. 
Method  of  Bier  and  Eiselsberg. 


Fig.  631. — Amputation  of  leg. 
Bier's  method. 


at  this  point,  little  if  any  need  would  arise  for  the  above  modifications.  In 
the  hands  of  the  author  the  amputation  described  on  page  517  et  seq.  has 
secured  excellent  results. 


532 


OPERATIVE  SURGERY. 


Sabanejeff's  Method. — Make  a  longitudinal  incision  at  either  side  of  the 
leg  from  the  head  of  the  fibula  and  from  the  internal  lateral  ligament  re- 
spectively downward  to  near  the  junction  of  the  middle  and  upper  thirds 
of  the  limb ;  connect  these  incisions  in  front  by  a  transverse  one  located  two 
fingers'  breadths  below  the  tubercle  of  the  tibia  and  behind  by  a  similar  in- 
cision made  somewhat  higher ;  reflect  a  posterior  skin  flap  up  to  the  knee  and 
tibio-fibular  joints ;  open  these  joints  from  behind  and  sever  the  crucial  and 
lateral  ligaments;  turn  the  leg  forward  against  the  anterior  surface  of  the 
thigh;  saw  off  the  lower  end  of  the  femur  (Fig.  632,  a),  and  so  form  a  bone 
flap  from  the  upper  and  anterior  aspect  of  the  tibia  as  to  include  the  inser- 
tion of  the  ligamentum  patellse,  and  place  this  flap  in  contact  with  the 
sawed  surface  of  the  femur,  where  it  should  remain  without  restraint 
(Fig.  632,  Ij). 

Amputation  of  the  Thigh. — The  muscles  sur- 
rounding the  thigh  are  of  large  size,  and  many 
of  them  of  great  length.  Those  on  the  pos- 
terior and  internal,  and  one  on  the  anterior  sur- 
face, extend  from  the  pelvis  to  the  leg. 

The  Special  Considerations. — The  greater  the 
length  of  a  muscle  from  its  origin  to  the  point  of 
division  the  more  marked  will  be  its  retraction, 
other  things  being  equal.  It  therefore  happens 
in  amputation  of  the  thigh,  unless  care  be  ex- 
ercised in  division  of  the  muscles,  that  the  bone 
protrudes  or  presses  too  strongly  against  the 
flap,  giving  it  an  undue  conicity,  or  otherwise  dis- 
torting the  stump.  The  position  in  which  the  limb 
rests  during  the  healing  process  also  has  an  influence  on  the  muscular  retrac- 
tion. For  instance,  if  the  limb  be  extended  during  the  division  of  the  mus- 
cles, the  posterior  and  internal  ones,  on  account  of  their  greater  length  and 
tension,  retract  the  most,  and  if  to  this  be  added  the  additional  retraction 
due  to  placing  the  stump  in  a  semiflexed  position  on  a  pillow,  or  to  swinging 
during  healing,  the  tendency  to  cause  tender,  painful,  and  otherwise  trouble- 
some stumjDs  is  increased.  To  avoid  this  sequel,  the  limb  should  be  held  as 
nearly  as  possible  at  the  same  angle  with  the  body,  when  the  muscles  are 
being  divided,  as  that  at  which  it  will  be  placed  when  the  dressing  is 
completed  and  during  the  process  of  recovery.  However,  at  the  middle 
and  upper  thirds  the  bone  is  quite  near  the  center  of  the  muscular  mass, 
and  the  muscles  contract  proportionately  less  here  than  at  the  lower  third. 

In  order  to  obviate  the  occurrence  of  the  danger  of  undue  shortening  of 
the  muscles  after  division  and  during  treatment,  it  will  not  be  amiss  in  the 
instances  of  low  amputations  of  the  thigh  to  divide  the  tendons  of  the  ham- 
strung muscles  at  once  through  the  primary  incision,  limited  to  the  lower 
border  of  the  flap.  This  act  will  promptly  permit  of  free  contraction,  and 
thereafter  these  same  muscles  can  be  again  divided  higher  up  with  the  others 
if  they  are  not  already  found  to  be  of  a  suitable  length.  It  should  not  be 
overlooked  at  first  that  apparently  too  long  flaps  often  prove  (especially  here) 


Fig.  632. 


—Sabanejeff's  am- 
putation. 


AMPUTATION  AT  THE   LOWER  EXTREMITY. 


533 


I— b 


to  have  l)ec'n  the  projxT  Icii^di.  When,  (luring  tlio  course  of  repair,  ap])re- 
hensions  arise  regarding  the  fitness  ol"  the  final  outcouie  in  instances  of  sus- 
pected short  flaps,  much  may  he  gained  by  applying  to  the  stump  traction 
by  means  of  adhesive  plaster,  pulley  and  weight.  Such  treatment  of  reced- 
ing coverings  may  save  the  surgeon  the  annoyance  and  chagrin  of  having 
to  remove  the  advancing  end  of  the  bone  in  order  to  receive  a  satisfactory 
result.  Greater  care  and  vigilance  are  requisite  in  securing  serviceable 
Vk^eight-bearing  stumps  than  those  not  required  to  meet  such  exacting  de- 
mands, and  the  greater  the  weight  required  the  greater  is  the  duty  imposed 
upon  all  concerned.  However,  if  the  periosteum  and  deep  muscular  tissues 
be  sewed  firmly  over  the  end  of  the  bone  at  the  outset  (Figs.  461,  462,  463) 
and  are  held  firmly  in  position  until  repair  has  taken  place,  little  doubt  need 
be  entertained  that  a  suitable  stump  will  result. 

The  following  are  common  methods  practiced  in 
amputation  of  the  thigh:  The  equilateral-flap  meth- 
od; the  hilateral-flap  method;  the  antero-posterior 
musculo-integumentary-flap  method;  the  circular  in- 
tegumentary-flap method;  the  high  circular-incision 
method;  the  long  anterior-flap  method;  the  long  an- 
terior- and  posterior-flap  method. 

The  Amputation  hy  the  Equilateral- flap  Method 
(Vermale). — The  flaps  in  this  method,  made  by  trans- 
fixion, are  musculo-cutaneous  and  U-shaped,  and  the 
length  of  each  is  equal  to  the  diameter  of  the  limlj 
at  the  point  of  amputation.  Great  care  should  be 
taken  that  the  transfixion  does  not  impale  the  femoral 
vessels;  if  the  inner  flap  be  made  the  broader  this 
danger  will  be  obviated.  In  this  method  of  operation 
the  surgeon  grasps  the  soft  parts  at  one  side  of  the 
thigh  with  the  thumb  and  fingers,  draws  them  vigor- 
ously away  from  the  bone,  then  passes  the  blade  of 
a  long  catlin  from  above  downward  close  to  the  bone, 
and  cuts  the  fiap  downward  and  outward  from  the 
bone  of  the  indicated  length ;  the  second  flap  is  made 
at  the  opposite  side  in  a  similar  manner  (Fig.  633,  h).  Both  flaps  are  then 
drawn  forcibly  upward,  and  the  bone  is  exposed  an  inch  above  the  point  of 
transfixion  and  divided  with  the  saw.  The  fiaps  are  united,  drained,  and  the 
wound  is  dressed  as  before.  If  amputation  be  performed  close  to  the  band  of 
a  tourniquet  or  the  elastic  bandage  of  Esmarch,  the  muscles  will  be  held  too 
firmly  to  permit  natural  retraction  until  after  the  bone  is  sawed  and  they 
are  liberated ;  this  is  a  fault  which  must  be  recognized  and  corrected  by  cut- 
ting the  muscles  lower  than  would  otherwise  be  done. 

The  Amputation  hy  the  Bilateral-flap  Method  (Fig.  617,  a,  c).— The 
bilateral-flap  method  is  admirably  adapted  to  amputation  at  the  middle  and 
lower  thirds  of  the  thigh. 

The  flaps  are  integumentary  and  their  outlines  are  formed  the  same  as 
in  amputation  of  the  leg  by  this  method.     They  are  dissected  up  from  the 


Pig.  633.-5.  Equilateral- 
flap  method,  a.  Bi- 
lateral-flap method. 


534 


OPERATIVE  SURGERY. 


muscles  three  inches,  or  about  half  their  length.     The  muscles  are  then 
divided  by  a  single  or  repeated  circular  sweeps  of  the  knife,  and  the  bone  is 

exposed  and,  after  the  formation  of  a  periosteal 
flap,  sawed  off  three  inches  higher  up.  In  circu- 
lar division  of  the  muscles,m  connection  with  any 
kind  of  flap,  it  is  advisable  that  the  first  sweep  of 
the  knife  should  divide  only  the  superficial  layer, 
which  will  then  retract,  or  can  be  drawn  upward 
when  the  second  layer  is  severed  at  a  higher 
point,  thus  causing  the  open  stump  to  present 
a  conical-shaped  cavity,  the  sawed  bone  corre- 
sponding to  the  apex  (Figs.  634  and  635). 

The  Amputation  hy  the  Antero-posterior  Mus- 
culo-integmnentary-flap  Method  (Figs.  480  and 
481). — These  flaps  include  all  of  the  tissues  down 

T^     nr,A     r^    ■    1  I.      J  to  the  bone,  and  are  usually  made  by  transfixion, 

Fig.  634. — Conical-shaped  cay-  '  .  -^  ■'  ,,- 

ity  from  repeated  circular   although  the  anterior  one  may  be  made  by  cutting 

incisions  of  muscles  in  cir-    f^om  without  and  the  posterior  by  transfixion 

cular-nap  amputation.  ^   ,,  i-     ■j_     p  .t      £  mi      i        ±t      £ 

at  the  upper  limit  ot  the  former.    The  length  oi 

each  should  be  about  one  third  the  circumference  of  the  limb.  When  both 
flaps  are  made  by  transflxion  the  tissues  should  be  raised  somewhat  by  the 
left  hand  of  the  operator,  who  then  enters  the  point  of 
the  knife  at  the  side  nearest  himself  and  pushes  it 
through  in  close  contact  with  the  anterior  surface  of 
the  bone,  depressing  the  handle  a  little  as  the  point 
reaches  the  bone  and  raising  it  a  little  after  the  point 
has  passed,  thus  causing  the  knife  to  emerge  on  the 
inner  side  of  the  limb  exactly  opposite  its  point  of  en- 
trance (Fig.  636,  6). 

The  flap  is  then  formed  by  cutting  obliquely  up- 
ward and  forward  with  a  sawing  motion  the  proper  dis- 
tance, and  when  completed  the  flap  is  pulled  backward 
by  an  assistant  assigned  for  that  purpose.  The  knife  is 
reinserted  at  the  original  point  of  entrance  and  carried 
behind  the  bone,  the  point  elevated  so  as  to  emerge 
at  the  same  situation  as  before,  and  the  posterior  flap 
is  made  by  cutting  obliquely  upward  and  backward. 
The  remaining  muscular  fibers  are  cut  by  a  circular 
sweep  of  the  knife,  retractors  applied,  and  the  bone  is 
divided  at  a  point  a  little  below  the  level  of  the  point 
of  transfixion.  The  end  is  then  seized  by  strong  for- 
ceps, the  soft  parts  on  its  posterior  surface  and  sides 
are  pushed  up,  and  with  a  small,  sharp-pointed  knife  Fig.  635.— Amputated 
an  oval-  or  rectangular-shaped  flap  of  periosteum  is  portion  with  ter- 
marked  out  and  pushed  upward  from  the  anterior 
surface  of  the  bone,  together  with  the  soft  parts  resting  upon  it  (Fig.  638). 
The  base  of  the  periosteal  flap  should  correspond  to  the  point  of  secondary 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


division  of  the  bone,  which  will  be  about  two  inches  above  the  primary  sec- 
tion. The  bone  is  sawed  again  and  removed.  The  portion  of  the  flap 
having  the  periosteum  is  allowed  to  fall  into  its  proper  position  across  the 
end  of  the  divided  femur,  the  edges  are  united,  and  the  stump  is  dressed  as 
desired.  In  flaps  of  this  structure  the  skin  retracts  more  than  the  muscles, 
causing  the  lower  ends  of  the  latter  to  be  exposed.  To  avoid  this  exposure, 
Agneiv  recommends  that  the  flaps  be  formed  first  from  the  integument, 
reflected  up  an  inch  and  a  half,  and 
that  the  muscles  be  divided  by  trans- 
fixion, the  point  of  the  knife  being 
pushed  through  at  the  junction  of  the 
reflected  integumentary  flaps. 

The  ampittation  hy  the  circular  in- 
tegumentary-flap method  can  be  em- 
ployed at  the  thigh,  with  admirable 
results;  but  owing  to  the  greater  con- 
traction of  the  muscles  at  the  posterior 
and  inner  aspect  of  the  thigh,  the  in- 
cision should  be  made  obliquely,  the 
anterior  and  outer  limit  of  the  flap 
being  located  about  two  and  a  half 
inches  nearer  the  line  of  proposed  bone 
division  than  is  the  posterior  and  inner 
limit  (Fig.  636,  a). 

First  carefully  mark  the  outline  of 
the  flap,  then  with  a  long  knife  or  a 
large  scalpel  fashion  the  flap  in  the 
course  of  the  line,  going  down  to  the 
muscles ;  free  the  integument  equally 
for  a  short  distance  all  around,  retract 
it,  and  divide  the  superficial  muscles  at 
the  inner  and  posterior  aspects  of  the 
limb  promptly ;  retract  these,  then  with 
a  circular  sweep  of  the  long  knife  sever 
the  remaining  muscles  parallel  with  the 
integumentary  incision,  at  the  highest 
point  practicable  ;  expose  the  bone,  ad-  Fig.  636.— a'.  Circular  amputation,  a. 
iust  the  retractor,  and  use  the  saw  as  Saw  line.  i.  Antero-posterior  method. 
,     .  „,  ,  •     i-  i!   .1  o.  Saw  line.     c.  External  racket  meth- 

before.     The  angular  projection  ot  the        qJ^  disarticulation. 

linea  aspera  is  removed  with  a  rongeur 

or  bone  forceps.  This  amputation  is  best  employed  at  the  lower  third  of 
the  thigh.  However,  when  practiced  at  either  of  the  other  thirds,  the  ob- 
liquity of  the  incision  is  lessened,  it  being  the  least  oblique  at  the  upper  third. 
Syme's  modification  of  this  method  is  easier  of  performance  than  the 
original,  and  consists  in  making  two  equal,  short,  antero-posterior  flaps  of 
integument  by  means  of  short,  lateral  incisions  at  either  aspect  of  the  thigh, 
carried  upward  from  a  circular  incision  of  the  integumentary  tissues  of  the 


536 


OPERATIVE  SURGERY. 


limb.    The  flaps,  and  two  inches  additional  of  integument  above  them,  are 
dissected  up,  and  the  exposed  muscles  are  divided  in  front  at  the  highest 

and  behind  at  the  lowest  point 
of  exposure,  down  to  the  bone. 
The  retractor  is  adjusted,  and 
the  bone  sawed  about  two  inches 
above  the  line  of  division  of  the 
anterior  muscles. 

The  Amputation  ty  the  Sin- 
gle Circular-incision  Method 
(Celsus). — With  a  long  knife 
divide  all  the  soft  parts  by  a 
circular  sweep  down  to  the 
bone  (Fig.  637),  which  is  then 
sawed  off. 

The  end  of  the  divided  bone 
is  now  seized  by  strong  forceps, 
and  the  surrounding  soft  parts 
are  drawn  upward,  when,  if  de- 
sirable, a  periosteal  flap  can  be 
made,  its  base  corresponding  to 
the  site  of  secondary  section  of 
the  bone  (Fig.  638).  Saw  the 
bone  a  second  time  close  to  the 
periosteal  flap,  and  allow  the 
parts  to  fall  into  position.  The 
amount  of  bone  to  be  removed 
at  the  second  division  is  estimated  the  same  as  is  the  length  of  the  flap  in 
other  amputations.  The  divided  borders  can  be  united  transversely 
(Fig.  639)  or  the  reverse;  the  former  union  holds  the  periosteal  flap 
in  position  the  better. 


Pig.  637. — Celsus's  single  circular  incision. 


Fig.  638.— Periosteal 


Fig.  639. — Appearance  of  stump. 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


The  Remarks. — This  method  is  of  interest  on  account  of  its  antiquity, 
and  also  from  the  fact  that  in  a  thigh  clothed  with  scantily  developed 
and  flexible  muscles  it  forms  a  serviceable  stump  with  a  minimum  area  of 
exposed  surface  of  the  soft  parts.  But  if  the  muscles  be  indurated  this 
method  ought  not  to  be  attempted.  If  the  periosteum  be  pushed  up  all 
around  and  remain  attached  to  the  surrounding  soft  parts,  the  injury  to 
the  muscles  is  still  further  lessened. 

The  Amputatio7i  hy  the  Long  Anterior -flap  Method  (Sedillot). — The  long 
anterior-flaj)  method  can  be'employed  at  any  portion  of  the  thigh.  Mark  out 
on  the  anterior  surface  of  the  limb  a  flap,  the 
length  of  which  is  equal  to  the  diameter  of  the 
limb  and  its  base  to  half  of  the  circumference 
at  the  saw  line.  Divide  the  tissues  obliquely, 
upward  and  backward,  not  making  the  flap  too 
thick.  The  tissues  on  the  posterior  portion  of 
the  limb  are  divided  transversely  down  to  the 
bone,  which  is  then  exposed  about  two  inches 
higher  and  sawed  off.  If  the  length  of  the 
anterior  flap  be  increased  by  about  a  quarter 
of  the  diameter  of  the  limb,  the  usefulness  of 
the  stump  will  be  improved. 

The  Amputation  hy  the  Long  Anterior-  and 
Short  Posterior-flap  Method  (Farabeuf)  (Fig. 
640,  a). — This  method  is  well  adapted  to  ampu- 
tation at  the  middle  of  the  thigh.  The  flaps 
are  U-shaped,  the  anterior  having  a  base  a  little 
broader  than  half  the  circumference  of  the  limb 
and  a  length  equal  to  one  and  a  half  diameters 
of  the  limb  at  the  point  of  amputation.  The 
posterior  flap  equals  in  length  one  half  the 
diameter  of  the  limb.  The  integumentary  struc- 
ture of  both  flaps  is  first  divided  with  a  large 
scalpel.  Then  the  tissues  of  the  anterior  flap 
are  pinched  up  with  the  thumb  and  fingers  and 
divided  obliquely  downward  and  upward  to  the 
bone  with  a  long  knife.  The  muscles  of  the 
posterior  flap  can  be  divided  from  without,  as  in  Fig.  640.— a.  Long  anterior-  and 
the  preceding  flap,  oi-  by  transfixion  and  obliqne  ffnlS^^  ZfX- 
downward  division.  The  flaps  are  then  retract-  articulation), 
ed,  and  the  bone  is  exposed  and  sawed  as  usual. 

The  General  Remarhs.—ln  amputation  at  the  thigh  the  periosteal  portion 
of  the  flaps  should  be  formed  to  correspond  as  nearly  as  practicable  with 
the  outlines  of  the  major  parts  of  the  flaps,  so  that  when  the  borders  of  the 
former  are  united  together  (Fig.  6-13)  the  end  of  the  bone  will  be  suitably 
covered. 

The  suturing  over  the  end  of  the  lone  of  a  recent  stump,  by  chromicized 
catgut,  of  a  periosteal  flap  (Figs.  6-il,  643),  along  with  its  immediate  nms- 
36 


538 


OPERATIVE  SURGERY. 


cular  tissue  connections  (Fig.  641),  exercise  an  important  preservative 
influence  on  the  nutrition  of  the  end  of  the  bone,  and  in  obviating  abnor- 
mal deviations  of  growth  (bony  spines),  and  also  in  limiting  undue  retraction 
of  the  deep  soft  tissues  at  that  situation.  When  this  measure  is  supple- 
mented by  buried  suture  apposition  of  the  overhanging  muscular  flaps 
(Fig.  642),  especially  in  the  instances  of  thigh  and  arm  amputation,  great 
benefit  follows,  because  muscular  retraction  of  the  entire  stump  is  inhib- 
ited, thereby  promoting  prompter  and  better  union  and  the  making  of  a 
better  stump.  In  the  absence  of  these  measures,  undue  muscular  retraction 
encouraged  by  a  fixed  position  of  the  stump  (especially  of  the  thigh)  leads 
much  too  frequently  to  an  unserviceable  caused  by  a  tender  protruding  bone. 


Fig.  641. — Amputation  of  thigh.     Perios- 
teum sewed  over  end  of  bone. 


Pig.  642. — Amputation  of  thigh.  Perios- 
teal flap  covered  in  and  muscles  united 
deeply  with  sutures. 


The  divided  ends  of  the  deep  and  of  the  superficial  layers  of  muscu- 
lar tissue  may  be  joined  together  respectively,  thus  opposing  retraction 
and  thereby  lessening  dead  spaces  and  covering  more  effectively  the  end  of 
the  bone  (Fig.  644).  The  unheeded  effect  on  the  stump  of  the  unusual 
length  of  the  muscles  of  the  thigh  and  of  their  strong  retractile  tendencies 
frequently  beget  conical  stumps  and  distorted  scars,  especially  at  the  lower 
half  of  the  limb. 

Although  the  antero-posterior  musculo-cutaneous-fiap  method  is  the  best 
all-round  plan  of  practice,  still  the  circular,  when  performed  with  due  con- 
sideration of  the  necessity  of  dividing  the  muscles  according  to  their  degree 
of  retraction,  hence  in  an  elliptical  manner  (Fig.  636,  a),  provides  an  excel- 
lent stump.  It  should  not  be  forgotten  that  the  transfixion  methods  sever 
muscles  of  unequal  lengths  and  different  degrees  of  contractility,  therefore, 
unevenness  of  the  flap  is  a  natural  consequence. 


AMPUTATION  AT   THE   LOWER  EXTREMITY. 


539 


The  After-treat  III  ctit. — Not  a  little  of  the  success  in  amputation  of  the 
thigh  depends  on  the  after-treatment  of  the  stump.  It  should  he  carefully 
surrounded  with  antise])tic  gauze  l)0und  in  place  with  sufficient  firmness  to 
support  the  soft  parts,  eliminate  dead  spaces,  and  equalize  the  circulation 
of  the  stump.  The  dressing  should  be  carried  around  the  pelvis,  to  prevent 
displacement  and  needless  exi)osure  of  surfaces  contiguous  to  the  wound 


Fig.  643. — Periosteum  covering  end  of  bone.        Fig.  644. — Ends  of  superficial  muscu- 
Ends  of  deep  muscles  approximated  with  lar  structures  approximated, 

sutures. 

(Fig.  645).  The  stump  should  be  slightly  raised,  and  placed  on  a  firm 
pillow  to  which  it  is  loosely  attached.  Drainage  should  be  provided  at  the 
most  dependent  portion  by  a  small  rubber  tube  extending  only  into  the 
wound  cavity,  or  by  wisps  of  horsehair  or  catgut.  If  lateral  flaps  have 
been  made  they  should  be  carefully  supported  or  their  weight  will  cause 
undue  tension  at  their  upper  junction.     In  fact,  the  sutures  should  be 


' ;  ;  .'.lit; 


Fig.  645. — Stump  dressed  with  anliseptic  gauze. 


permitted  to  remain  longer  here  than  elsewliere  in  the  line  of  coaptation, 
for  the  reason  that  there  is  greater  danger  of  traction  at  this  point.  If  the 
patient  be  restless  or  delirious  and  move  the  stump  frequently  the  danger  of 
eonicity  is  thus  increased.  In  such  cases  it  is  our  practice  to  apply  con- 
tinuous extension  to  the  soft  parts  of  the  stump  by  means  of  a  rubber  band 
fastened  to  them  at  one  end  with  adhesive  straps  and  the  other  passed  over 


540 


OPERATIVE  SURGERY. 


the  distal  end  of  a  perineal  crutch,  thus  keeping  up  continuous  extension 
even  if  the  stump  be  moved  b}^  the  patient. 

The  Results. — The  rate  of  mortality  in  amputation  at  the  lower  third  of 
the  thigh  for  gunshot  injuries  is  fift3r-five  per  cent,  at  the  middle  third  sixty- 
five  per  cent,  and  at  the  upper  third  seventy-eight  per  cent.  About  thirteen 
per  cent  more  recover  with  expectant  treatment,  in  gunshot  injuries,  than 
after  amputation.  The  rate  of  mortality  after  primary  amputations  is 
twenty-one  per  cent  greater  than  after  secondary.  The  results  are  much 
more  favorable  when  done  in  private  practice,  or  with  antiseptic  precautions 
irrespective  of  the  cause. 

Later  Results. — Of  7,360  amputations  of  the  thigh  for  all  causes, 
6,245  were  done  during  the  pre-aseptic  period  with  a  mortality  of 
43.66  per  cent,  and  1,115  under  asepsis,  of  which  21.0  per  cent  ter- 
minated fatally. 

Amputation  through  the  trochanters  is  safer  than  disarticulation  at  the 
hip-joint  and  may  be  practiced  instead  of  the  latter  in  instances  of  injury, 
and  of  tumors  of  the  femur  when  the  bone  is  not  involved  at  the  seat  of  am- 
putation, and  when  good  judgment  favors  the  former. 

Amputation  at  the  Hip  (Disarticulation). — The  causes  of  death  from 
this  amputation  are  loss  of  blood,  shock,  and  septicaemia.    Various  plans  to 

limit  the  loss  of  blood  have  been  suggested, 
such  as  compression  of  the  abdominal  aorta 
by  the  fingers  of  an  assistant  with  the  hand 
introduced  into  the  rectum,  combined  with 
digital  pressure  upon  the  femoral  as  it  crosses 
the  pubis.     In  all  instances  when  abdominal 


Fig.  646. — Paneoast's  tourniquet. 


Fig.  647. — Esmarch's  tourniqueto 


pressure  is  to  be  applied  the  intestines  should  have  been  previously  evacuated. 
The  application  of  the  pressure  to  the  part  of  the  median  line  of  the  abdo- 
men at  which  the  pulsation  of  the  vessel  is  the  best  determined  should  be 
considered,  although  not  necessarily  adopted.  In  patients  with  unusual  adi- 
pose development  the  measure  is  of  no  use,  and  its  employment  may  be  pos- 
itively harmful.  For  another  purpose  in  patients  with  unusually  sensitive 
abdominal  tissues  the  pressure  is  illy  borne  and  may  be  positively  unendur- 
able without  anaesthesia.    Various  forms  of  tourniquets  have  been  designed 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


541 


for  the  purpose,  as  Pancoast's  (Fig.  046),  Esmarch's  (Fig.  047),  and  Lis- 
ters (Fig.  048).     Fig.  049  s^iows  Esmarch's  elastic  tourniquet  in  position. 
If  a  tourniquet  be  not  at  hand,  a  pad  may  be  substituted  made  by  wind- 
ing a  linen  bandage  about  three  inches  wide  and  twenty-five  feet  in  length 


Fig.  648. — Lister's  tourniquet. 


Fig.  649. — Esmarch's  tourniquet  applied. 


around  a  stout  rod  or  stick  one  inch  or  so  in  diameter  and  twelve  inches 
long,  which  is  placed  immediately  below  the  umbilicus  and  held  in  position 
by  an  assistant. 

It  can  be  held  in  position,  and  the  pressure  still  further  increased,  by 
several  turns  of  a  rubber  bandage  carried  over  it  and  around  the  body 
(Fig.  050). 

If  the  elastic  traction  around  the  body  be  objectionable,  a  longer  stick 


Fig.  050. — Compressed  pad  and  elastic  band. 


can  be  substituted,  and  the  compress  secured  in  position  by  rubber  bands 
carried  over  the  ends  of  the  stick  and  under  the  table  (Fig.  051). 

Davy's  lever  (Fig.  91)  is  a  useful  agent  to  control  ha?morrhage  at  this 
situation.    The  lever  is  open  to  the  objection  of  being  easily  disturbed  by 


542  OPERATIVE  SURGERY. 

the  struggles  of  the  patient,  and  the  danger  of  injuring  the  intestines,  espe- 
cially when  carried  to  the  right  side  of  the  body. 

Trendelenburg'' s  rod  (Fig.  92)  has  been  mentioned,  and  is  of  unques- 
tionable utility.  It  is  a  steel  rod  fifteen  or  sixteen  inches  long,  about  one 
fourth  of  an  inch  broad,  biconvex  on  transverse  section,  and  a  twelfth  of 
an  inch  thick  at  the  center,  with  blunt  edges,  but  provided  with  a  movable, 
lance-shaped  point  two  inches  in  length.  The  rod  is  passed  through  the 
soft  parts  in  front  of  the  joint,  entering  an  inch  and  a  half  below  the  ante- 
rior superior  spinous  process  of  the  ilium,  passing  across  the  femur  behind 
the  femoral  artery,  and  emerging  at  the  posterior  scroto-femoral  junction. 
The  point  is  removed,  and  a  strong  elastic  tube  or  band  is  wound  firmly, 
like  the  figure  8,  around  its  ends,  passing  in  front  of  the  thigh.  A  long 
knife  is  then  inserted  in  the  course  of  the  rod  about  half  an  inch  below  it, 
and  the  anterior  flap  made  in  the  usual  manner  and  the  vessels  ligated. 
The  rod  is  then  withdrawn,  the  hip  joint  disarticulated,  and  the  posterior 
flap  is  made.     The  late  Dr.  Varick,  of  Jersey  City,  N.  J.,  who  first  employed 


nilflil 
Fig.  GOl. — I'luudisV  iiielhod  ol  cunipieb'^ion. 

the  rod  in  this  country,  did  not  disarticulate  until  he  had  transfixed  a  sec- 
ond time  behind  the  neck  of  the  femur,  including  as  much  of  the  soft  parts 
on  the  posterior  surface  as  possible  ;  compression  with  the  rod  was  then 
applied  as  before,  and  the  tissues  were  divided  by  a  posterior  semicircular 
incision  down  to  the  bone.  The  amount  of  blood  lost  was  trifling,  and  the 
patient  made  a  speedy  recovery.  The  rod  can  be  employed  in  the  various 
forms  of  flaps,  but  it  has  not  as  yet  been  enough  used  to  be  esteemed  more 
than  a  rational  expedient. 

WyetWs  modification  of  the  application  of  the  principles  of  the  Trendel- 
enburg method  is  a  decided  improvement  on  the  original.  Wyeth  employs 
two  instead  of  one  fixation  agent,  and  constricts  the  entire  limb  above  these 
agents,  instead  of  a  portion  of  the  limb  against  the  single  agent. 

The  following  is  a  description  of  this  modification  as  applied  to  the  hip 
joint:  If  the  condition  of  the  limb  will  permit,  draw  the  hip  well  over  the 
edge  of  the  table,  and  apply  an  Esmarch  bandage  to  the  entire  extremity  and 


AMPUTATION   AT   THE   LOWER  EXTREMITY. 


543 


up  as  closely  to  the  perineum  as  practicable.  The  point  of  a  steel  mattress 
needle,  three  sixteenths  of  an  inch  in  diameter  at  the  base  and  one  foot  long, 
is  inserted  one  fourth  of  an  inch  below  and  slightl}^  to  the  inner  side  of  the 
anterior  superior  spinous  process  of  the  ilium,  and  carried  superficially 
through  the  tissues  at  the  outer  side  of  the  hip,  emerging  on  a  level  with  the 
point  of  entrance.  A  second  needle  is  then  inserted  internally  through  the 
adductor  longus  half  an  inch  below  the  perineum,  emerging  an  inch  below 
the  tuber  ischii  of  the  same  side.  After  covering  the  needle  points  with 
corks,  a  long  piece  of  half-inch  rubber  tubing  is  passed  while  on  the 
stretch  five  or  six  times  tightly  around  the  thigh  above  the  needles  and 
fastened  with  a  clamp  or  by  tying,  after  which  the  Esmarch  bandage  is 
removed.     A  circular  nniseulo-cutancous  flap  is  then  made,  Ijeginning  five 


/ ^- 

^•> 

V. 

\ 

i 

i 

'^ 

:.  rife^s^^- ■■■"'■'• 

Fig.  652. — Hip-joint  amputation.     Pius  and  rubber-tube  tourniquet  in  position. 
Esmarch  bandage  has  been  removed. 


The 


inches  below  the  ruljber  cord  and  extending  up  to  the  trochanter  minor;  if 
necessary  to  proper  action,  this  flap  can  be  incised  behind  and  also  in  front 
in  the  long  axis  of  the  limb  (Fig.  652). 

The  muscles  are  then  divided  at  the  upper  limit  of  the  flap  by  a  circular 
sweep  of  a  long  knife.  The  bone  is  sawed  through  at  this  or  at  a  lower 
point  (Fig.  653) ;  if  at  the  latter,  better  fulcrumage  is  gained  in  aid  of 
a  subsequent  step  of  the  operation — dislocation  of  the  head  of  the  bone 
(Fig.  654).  The  visible  ends  of  all  divided  vessels  are  secured,  and  the 
rubber  cord  is  loosened  carefully  and  slowly  and  finally  removed,  the  bleed- 
ing points  being  caught  as  soon  as  they  appear.  The  remaining  portion 
of  the  femur  is  freed  from  its  muscular  attachments ;  the  capsule  and  coty- 
loid ligament  are  divided  posteriorly  by  the  sharp  point  of  the  knife,  and 


544 


OPERATIVE   SURGERY. 


the  lower  extremity  of  the  bone  is  carried  forcibly  upward  and  inward  until 
luxation  occurs;  the  round  ligament  and  the  capsule  are  divided  and  the 


IV. 


\\ 


f 


Fig.  653. — The  same,  showing  the  soft  parts  dissected  from  the  bone  and  the  capsule 

exposed. 

bone  is  removed.     The  flaps  are  united  antero-posteriorly  and  the  wound 
drained  (Fig.  655). 


^  .^^1.^. 


Fig.  654. — The  same,  with  the  disarticulation  complete.      Constrictor  still   in  position, 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


545 


An  admirable  method  of  controlling  litemorrhage  in  amputation  at  the 
hip  joint  has  recently  been  described  (Lloyd)  : 

"  A  strip  of  black  india-rubber  bandage  two  yards  long  is  to  be  doubled 
and  passed  between  the  thighs,  its  center  lying  between  the  tuber  ischium  of 
the  side  to  be  operated  on  and  the  anus.  A  common  calico  thigh  roller 
must  next  be  laid  lengthwise  over  the  external  iliac  artery.  The  ends  of  the 
rubber  are  now  to  be  firmly  and  steadily  drawn  in  a  direction  upward  and 
outward,  one  in  front  and  one  behind,  to  a  point  above  the  center  of  the 
iliac  crest  of  the  same  side.  They  must  be  pulled  tightly  enough  to  cbeck 
pulsation  in  the  femoral  artery.  The  front  part  of  the  band,  passing  across 
the  compress,  occludes  the  external  iliac  artery,  and  runs  parallel  to  and  a 
little  above  Poupart's  ligament.     The  back  half  of  the  band  runs  across  the 


^%.^ 


Fig.  655. — Tlie  operation  completed. 

great  sacro-sciatic  notch,  and,  by  compressing  the  vessels,  prevents  bleeding 
from  the  branches  of  the  internal  iliac  artery  which  pass  through  it.  The 
ends  of  the  elastic  band  can  be  held  by  the  hands  of  an  assistant,  or  bandages 
may  be  tied  to  its  extremities  and  passed  across  the  opposite  shoulder  and 
tied ;  care  should  be  taken  to  prevent  the  compression  rollers  from  slipping. 
This  device  has  been  employed  on  several  occasions  with  entire  satisfaction." 
McBurney  has  advised  and  practiced  a  most  valuable  suggestion,  espe- 
cially for  those  cases  in  which  disease  of  the  upper  end  of  the  tliigh  interferes 
with  the  circular  constriction  method.  The  finger  of  an  assistant  is  intro- 
duced into  the  abdomen  through  the  "  gridiron  "  incision  for  appendicitis 
(Vol.  II),  carried  over  the  psoas  muscle,  placed  on  the  common  iliac  artery, 
flexed  and  drawn  outward  so  as  to  press  the  artery  against  the  inner  border 
of  the  muscle,  thus  easily  and  effectually  controlling  the  haemorrhage.     Of 


546 


OPERATIVE  SURGERY. 


course,  strict  asepsis  must  be  practiced,  or  an  element  of  great  danger  will  be 
added  to  the  operation. 

TilcLen  Brown  devised  a  clamp  to  control  the  circulation  of  the  femoral 
during  amputation. 

The  plans  of  Wyeth  and  McBurney  appear  to  the  writer  to  meet  the 
demands  of  the  operation  better  than  any  yet  devised. 

Shock  is  certain  to  happen  in  amputation  of  the  thigh,  and  the  occur- 
rence should  be  anticipated  in  order  that  it  may  be  treated  successfully.  Not 
only  should  the  patient  be  prepared  for  the  occurrence  of  shock,  but  also  the 
surgeon  should  have  at  command  the  recognized  agents  of  relief  (page  121 
et  seq.).  The  body  should  be  warmly  enveloped  with  flannel  at  the  outset, 
and,  too,  bottles  of  hot  water  may  be  applied  at  the  time  of  the  operation. 

The  Results. — Of  267  cases  done  by  this  method  for  all  causes,  53,  or 
19.8  per  cent,  died;  137  were  for  malignant  disease,  14.10  per  cent  died; 
94  for  infection,  mortality  16.7  per  cent,  and  36  for  injury,  of  which  63.9 
per  cent  died.     (Wyeth.) 

Senns  bloodless  amputation  at  the  hip- joint:  Make  (according  to 
Senn) 

"  A  straight  incision  (beginning  about  three  inches  above  the  upper 
border  of  the  great  trochanter)  of  about  eight  inches  in  length  directly 


Fig.  656. — Senn's   bloodless   amputation   at  the  hip-joint.      Head  of  femur  dislocated 
through  incision.     Elastic  constrictors  in  place,  anterior  one  tied. 

over  the  center  of  the  great  trochanter  and  parallel  to  the  long  axis  of  the 
limb.  When  the  knife  reaches  the  great  trochanter,  its  point  should  be 
kept  in  contact  with  the  bone  the  whole  length  of  the  remaining  part  of  the 
incision.    The  margins  of  the  wound  are  now  retracted,  and  any  spurting 


AMPUTATION   AT   THE   LOWER  EXTREMITY.  547 

vessels,  such  as  the  circiimllcx  arteries,  secured  by  applying  pressure  for- 
ceps. During  this  and  the  remaining  steps  of  the  operation  the  body  is 
drawn  down  so  that  the  pelvis  rests  upon  the  lower  edge  of  the  table,  in 
order  that  the  thigh  can  be  manij)ulated  freely  by  the  assistant  who  is 
entrusted  with  this  work  (Fig.  65G).  The  trochanteric  muscular  attach- 
ments are  now  severed  close  to  the  bone  with  a  stout  scalpel.  The  clear- 
ing of  the  digital  fossa  and  the  division  of  the  tendon  of  the  obturator 
externus  require  special  care.     The  thigh  is  now  flexed,  strongly  adducted, 


Fig.  657. — Semi's  bloodless  ami)utatioii  at  the  hip-joint.     Elastic  constriction  completed. 
Antero-posterior  flaps  formed  of  all  tissues  down  to  muscles. 

rotated  inward,  when  the  capsular  ligament  is  divided  transversely  at  its 
upper  and  posterior  aspect.  The  remaining  portion  of  the  capsular  liga- 
ment is  severed,  while  the  thigh  is  brought  back  to  a  position  of  slight 
flexion,  after  which  it  is  rotated  outward,  and,  if  possible,  the  ligamentum 
teres  is  cut.  If  this  can  not  be  done,  the  head  of  the  bone  is  forcibly  dis- 
located upon  the  dorsum  of  the  ilium  by  flexion,  adduction,  and  rotation 
inward  of  the  thigh.  After  dislocation  has  been  effected,  the  trochanter 
minor  and  the  upper  part  of  the  shaft  of  the  femur  are  cleared  by  using 
scalpel  and  periosteal  elevator  alternately.  At  the  completion  of  this  part 
of  the  operation  the  femur  is  in  a  position  of  extreme  adduction,  and  the 
upper  portion  projects  some  distance  from  the  surface  of  the  wound. 

During  the  operation,  if  the  surgeon  has  kept  in  close  contact  with 
the  bone,  and  has  used  the  knife  sparingly  and  the  periosteal  elevator 
freely,  the  ht'emorrhage  has  been  slight,  much  more  so  than  if  this  part  of 
the  operation  had  been  reserved  for  the  last,  as  is  done  in  von  Esmarch's 
and  Wyeth's  methods.  Elastic  constriction  is  now  applied  in  the  following 
manner:  The  limb  is  brought  down  in  a  straight  line  with  the  body,  the 
thigh  is  slightly  flexed  so  as  to  push  the  upper  free  end  of  the  femur  for- 
ward into  and  beyond  the  wound,  when  a  long,  stout  hasmostatic  forceps 
is  inserted  into  the  wound  behind  the  femur  and  on  a  level  with  the  tro- 
chanter minor  when  in  a  normal  position.  The  instrument  is  then  pushed 
inward  and  downward  two  inches  below  the  i-amus  of  the  ischium  and  just 
behind  the  adductor  muscles.     As  soon  as  the  jioint  can  l)e  felt  under  the 


548  OPERATIVE  SURGERY. 

skin  in  this  location,  an  incision  is  made  through  the  skin,  about  two  inches 
in  length,  through  which  the  instrument  is  made  to  emerge.  After  en- 
larging the  tunnel  made  in  the  soft  tissues  by  dilating  the  branches  of 
the  forceps,  a  piece  of  aseptic  rubber  tubing  three  quarters  of  an  inch  in 
diameter  and  about  three  or  four  feet  in  length  is  grasped  with  the  forceps 
in  the  middle  and  is  drawn  along  the  tunnel  as  the  forceps  are  withdrawn, 
whereupon  the  rubber  tube  is  cut  in  two  at  the  point  where  it  was  held  by 
the  forceps.  With  one  half  of  the  tube  the  anterior  segment  of  the  thigh 
is  constricted  sufficiently  firmly  to  intercept  both  the  arterial  and  venous 
circulations  completely.  Before  the  constrictor  is  tied  the  limb  should  be 
held  in  the  vertical  position  for  a  sufficient  length  of  time  to  render  it 
practically  bloodless.  The  elastic  constrictor  is  either  tied,  or,  still  better, 
after  having  secured  the  necessary  degree  of  constriction,  it  is  held  with  a 
pair  of  forceps  at  the  point  of  crossing.  The  posterior  segment  of  the 
thigh  is  constricted  by  the  remaining  half  of  the  tube,  which  is  drawn 
sufficiently  tight  behind,  when  the  ends  of  the  tube  are  made  to  cross  each 
other  and  are  brought  forward  and  made  to  include  the  anterior  segment, 
when  they  are  again  firmly  drawn  and  tied,  or  otherwise  fastened,  above  the 


Fig.  658. — Senn's  bloodless  amputation  at  the  hip-joint.     Amputation  completed. 
Vessels  handy  for  ligature. 

first  constrictor  (Fig.  657).  As  the  anterior  segment  of  the  thigh  contains 
the  principal  blood-vessels,  this  method  of  applying  the  posterior  constrictor 
furnishes  an  additional  security  against  haemorrhage  from  the  large  vessels 
when  cut  during  the  amputation  (Fig.  658).  After  the  principal  blood-ves- 
sels have  been  tied,  the  posterior  constrictor  is  removed  and  additional 
bleeding  points  are  secured  before  the  anterior  constrictor  is  removed,    Sur- 


AMPUTATION   AT  THE   LOWER  EXTREMITY.  549 

face  compression  with  a  compress  wrung  out  of  a  liot  normal  salt  solution  is 
a  valuable  aid  in  minimizing  the  haemorrhage  after  tlie  removal  of  the  con- 
strictors. As  this  method  of  controlling  haemorrhage  does  not  require  the 
presence  of  a  skilled  assistant,  it  will  prove  of  special  value  in  emergency 
cases  (Fig.  ()59).     The  operation  can  be  performed  with  the  instruments 


Fig.  65y. — teeuiis  biuodiess  ampiaatiuii  at  the  liip-joint.     Stump  from  a  long  potilerior 

cutaneous  flap. 

contained  in  every  pocket  case.  Should  an  elastic  tube  not  be  at  hand,  the 
constriction  can  be  made  in  a  satisfactory  manner  by  substituting  for  it  a 
cord  made  of  sterile  gauze,  tightened  with  a  lever  of  some  kind,  as  is  done 
in  applying  the  ordinary  Spanish  windlass." 

Amputation  at  the  hip-joint  may  be  done  by  any  of  the  following  meth- 
ods: By  the  external-racket  method;  hy  the  anterior-racl'et  method;  hy  the 
long  anterior-  and  short  posterior-flap  method  (Manec);  hy  the  circular-flap 
method  (Dieffenbach) ;  hy  the  Furneaux-J ordan  method;  hy  the  antero-pos- 
terior-flap  method  (Guthrie);  and  hy  the  single-flap  method  (Malgaigne's). 

The  Amputation  hythe  External-rachet  il/c^/io(? (Disarticulation). — ^After 
complete  control  of  the  circulation  is  attained,  adduct,  flex  somewhat,  and 
rotate  the  thigh  inward;  make  an  incision  from  a  point  two  inches  above 
the  end  of  the  great  trochanter  downward  along  the  posterior  border  of  the 
same,  seven  inches  in  length  (Fig.  G36,  c) ;  connect  internally  the  lower  end 
of  this  incision  with  crescent-shaped  incisions  of  equal  length  at  either 
surface  of  the  limb  which  join  each  other  at  a  lower  point  than  that  of  the 
beginning.  These  incisions  are  made  through  the  integument  and  subcu- 
taneous tissue  only.  The  flap  embracing  the  limb  is  dissected  up  for  two 
inches;  the  vertical  incision  deepened  to  the  bone;  the  muscular  attach- 
ments to  the  great  trochanter  are  severed ;  the  portion  of  the  femur  cor- 
responding to  the  vertical  incision  is  cleared;  then  adduct  the  limb  strongly 


550 


OPERATIVE   SURGERY. 


and  divide  the  capsule  at  the  upper  and  posterior  part;  sever  the  remain- 
ing portion  of  the  capsule ;  dislocate  the  head  of  the  bone ;  divide  the  round 
ligament;  free  the  upper  part  of  the  femur  and  cut  the  muscles  at  the 
remaining  aspects  of  the  limb  on  a  level  with  the  reflected  flap  with  a  vigor- 
ous sweep  of  the  knife. 

Lister  made  the  vertical  incision  eight  inches  in  length,  and  divided  the 
muscles  by  a  circular  sweep  before  exposure  of  the  upper  end  of  the  bone, 
disarticulation  being  the  final  step  of  the  procedure. 

The  external-racket  incision  and  its  modifications  are  admirably  adapted 
for  amputation  here,  as  they  reduce  the  loss  of  blood  to  a  minimum,  afford 
good  drainage,  locate  the  scar  in  an  advantageous  position,  and  remove  the 
incision  from  the  prejudicial  influences  of  anal  proximity. 

Amputation  by  the  Anterior-racket  Method. — An  incision  of  the  skin 
and  subcutaneous  tissue  is  begun  at  the  center  of  Poupart's  ligament  and 
carried  downward  along  the  course  of  the  vessels  for  three  inches,  then 
inward  over  the  inner  aspect  of  the  limb  four  inches  below  the  genito- 
crural  junction,  thence  over  the  posterior  aspect  to  the  outer  surface  of  the 
limb,  just  below  the  great  trochanter,  then  upward  obliquely  across  the 
anterior  surface  of  the  thigh,  meeting  the  primary  incision  two  inches  below 


Fig.  660.— Manee's  method. 


the  commencement.  Expose  the  femoral  sheath  at  the  uppermost  incision, 
bare  the  vessels,  tie  each  one  independently  with  two  ligatures  and  sever 
the  portions  between  them;  liberate  and  retract  the  skin  along  the 
border  of  the  entire  flap ;  divide  the  superficial  muscles  at  the  outer  aspect 
with  a  scalpel ;  divide  the  circumflex  artery  thus  exposed  between  two  liga- 
tures; rotate  the  limb  inward  and   divide  the  insertion   of  the   gluteus 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


)51 


maximus,  then  outward,  and  sc'\('r  tlu'  psoas;  expose,  secure,  aud  divide  the 
internal  circunillex  as  in  the  preceding  instance;  employ  retractors  and  cut 
the  superficial  muscles  at  the  inner  aspect  of  the  limb  on  a  level  with  the 
retracted  skin ;  adduct  and  rotate  the  thigh  inward  and  free  the  trochanter 
from  muscular  insertions;  rotate  it  outward  and  cut  the  capsule  trans- 
versel}';  steady  the  pelvis  and  bear  down  on  the  limb,  thus  dislocating  the 
bone;  divide  the  round  ligament,  draw  the  head  of  the  bone  forward  and 
carry  a  knife  behind  it,  and  with  a  downward  and  outward  sweep  sever  the  re- 
maining tissues  on  a  level  with  the  retracted  skin,  thereby  removing  the  limb. 

The  anterior-racket  incision  offers  prompt  control  of  hemorrhage  and 
easy  disarticulation,  in  addition  to  other  common  advantages.  However, 
the  technique  of  the  procedure  is  not  as  simple  as  that  of  the  external-racket 
method. 

Amputation  hy  a  Lcng  Anterior-  and  Short  Posterior-flap  (Manec). — 
Place  the  patient  on  the  table  so  that  half  the  pelvis,  on  the  side  to  be  oper- 
ated upon,  projects  beyond  the  edge ;  draw  the  scrotum  to  the  opposite  side 
by  a  towel  (Fig.  660).  Exsanguinate  the  limb  by  the  elastic  bandage;  after 
which  control  the  haemorrhage  from 
above  by  the  form  of  arterial  com- 
pression selected,  and  remove  the 
elastic  bandage.  The  limb  to  be 
amputated  is  held  by  one  assistant, 
and  another  is  instructed  to  control 
the  circulation  in  the  femoral  artery 
as  it  crosses  the  pubes,  and  to  catch 
the  anterior  flap  and  compress  it  be- 
fore it  shall  have  been  completely 
severed  below. 

The  operator  then  introduces  the 
point  of  a  long  knife  midway  between 
the  anterior  superior  spinous  process 
of  the  ilium  and  the  trochanter  ma- 
jor, pushing  it  down  to  the  bone 
parallel  with  Poupart's  ligament; 
draws  it  back  a  little  and  lowers 
the  handle  and  carries  it  upward  (Fig.  661),  at  which  time  the  assistant 
flexes  the  thigh  slightly;  the  operator  then  passes  the  point  of  the  knife 
through  the  anterior  portion  of  the  capsular  ligament;  thence  downward, 
inward,  and  out  at  the  inner  side  of  the  thigh,  an  inch  or  so  below  the  peri- 
neum, and  as  far  posteriorly  as  can  be  easily  done  (Fig.  661).  The  knife 
is  then  carried  downward,  in  contact  with  the  Idouc,  with  long,  sawing  strokes, 
forming  an  anterior  flap  six  to  eight  inches  in  length.  The  flap  is  caught 
by  an  assistant,  who  at  the  same  time  compresses  the  main  vessel  within  it 
with  the  fingers  and  raises  the  flap  upward.  The  knife  is  then  carried  pos- 
teriorly between  the  thighs  (Fig.  662),  thence  outward  in  a  curved  direc- 
tion, passing  below  the  gluteal  fold,  and  going  down  to  the  bone,  thus  form- 
ing the  posterior  flap.    The  bone  is  disarticulated  by  dividing  the  capsular 


Fig.  6Ci1. — Transfixing. 


552 


OPERATIVE  SURGERY. 


ligament  and  the  muscular  attachments  to  the  greater  and  lesser  trochanters, 
and  the  limb  removed. 


Fig.  662. — Making  posterior  flap. 

Bring  the  flaps  into  position,  unite  them  with  sutures,  and  insert  a  long, 
large  drainage  tube  into  the  acetabulum,  allowing  it  to  protrude  at  the 
centre  of  the  line  of  union  (Fig.  663). 


Fig.  663.— Flaps  united. 

Amputation  hy  the  Circular-flap  Method  (Dieffenbach). — Control  the 
hsemorrhage  as  before,  or  by  means  of  the  elastic  ligature  (Fig.  664),  and 
with  a  long  knife  make  a  circular  incision  down  to  the  bone,  which  is  then 
sawed  through  (Fig.  665).     Tie  all  vessels,  veins  included.     Remove  the 


AMPUTATION  AT  THE  LOWER  EXTREMITY. 


553 


elastic  ligature,  secure  all  bleeding  points,  and  inserting  a  knife  two  iYiches 
above  the  great  trochanter,  at  its  outer  side,  carry  it  down  to  the  bone, 
over  the  middle  of  the  trochanter,  as  in  Fig.  G68,  and  along  the  outer 
surface  of  the  femur  to  the  circular  incision.    Then  seize  the  bone  with  a 


Fig.  664.— Elastic  ligature. 

strong  forceps,  separate  the  edges  of  the  vertical  incision,  and  remove  the 
periosteum  with  a  suitable  instrument  down  to  the  points  of  muscular 
insertion.  These  must  be  separated  with  a  knife,  the  edge  directed  toward 
the  bone.    Eemove  the  periosteum  in  this  manner  up  to  the  capsule  (Fig. 


Fig.  665. — Dieffenbach's  circular  method. 

666),  which  is  opened  and  the  head  dislocated.  The  last  step  of  the  opera- 
tion is  attended  with  but  slight  loss  of  blood.  Fig.  667  shows  the  appearance 
of  the  parts  after  their  coaptation.  An  additional  drainage  tube  is  inserted 
at  the  lower  extremity  of  the  wound.  If  it  be  impossible  to  employ  the 
bloodless  method,  the  femoral  vessels  should  be  secured  in  two  situations  by 
37 


554 


OPERATIVE  SURGERY. 


forceps  or  ligatures  at  the  base  of  Scarpa's  triangle,  and  divided  between 
them  (Fig.  665). 

Dieffenbaclis  plan  can  be  rapidly  executed,  and  the  lessened  disturbance 
of  the  soft  parts  attendant  on  removal  of  the  periosteum  is  a  desideratum. 


^^^lil 


Fig.  666. — Removing  the  bone. 


Amputation  hy  the  Furneaux  Jordan  Method. — This  method  contem- 
plates low  division  of  the  soft  parts,  thus  obviating  the  increased  danger 

from  shock  attendant  on  high 
division  of  those  structures, 
also  the  attainment  of  the  pur- 
pose with  a  minimum  loss  of 
blood. 

The  Operation.  —  Make  a 
straight  incision  down  to  the 
bone  from  a  point  just  above 
the  trochanter  major  down- 
ward along  the  outer  surface  of 
the  thigh  to  the  point  of  pro- 
posed circular  division  of  the 
soft  parts  (Fig.  668)  ;  free  the 
trochanter  and  the  upper  part 
of  the  shaft  from  the  muscular  attachments;  open  the  capsule  of  the  hip- 
joint  and  dislocate  the  head  of  the  femur ;  separate  the  tissues  from  the  bone 
down  to  the  point  of  intended  division  and  sever  them  there  by  a  circular 
sweep  of  the  knife.  Saw  off  the  bone,  seize  the  end  with  forceps,  complete 
its  separation  from  the  soft  parts  and  remove  it.     The  sawing  of  the  bone 


Fig.  667.— Wound  closed. 


AMPUTATION   AT   THE   LOWER  EXTREMITY. 


555 


is  a  matter  of  coiivcnicju'o,  since  it  liglitons  llic  hiirdcii  by  removal  of  the 
limb. 

Amputation  hij  the  Antero-posterior-flap  Method  (Guthrie). — The  pos- 
terior flap  is  laid  out  first,  by  an  incision  commenced  at  a  point  a  little 
above  the  srreat  trochanter  and  carried  downward  and  inward  in  a  curved 


Pig.  668. — Vertical  and  cii-eular 
incisions  (Furneaux  Jordan). 


Fig.  669. — Antero-posterior  flap  (Guthrie). 


direction  across  the  posterior  surface  of  the  thigh,  then  upward  and  inward 
in  a  similar  manner  to  a  point  in  front  of  the  tuber  ischii  (Fig.  669).    The 
anterior  flap  is  made  at  the  anterior  surface  of  the  thigh  by  a  corresponding 
incision  beginning  and  terminating  at  the  same 
points  as  the  preceding.     Each  flap  is  made  not 
less  than  five  inches  in  length,  and  the  first  inci- 
sions are  limited  to  the  division  of  the  integu- 
ment and  subcutaneous  tissues.     After  retraction 
of  these  flaps  the  muscular  structures  are  divided. 
in  the  same  order  as  the  preceding  ones,  from  be- 
low upward  in  an  oblique  manner  until  the  joint 
is  reached,  after  which  disarticulation  is  effected 
in  the  usual  way. 

This  method  provides  an  excellent  stump  with 
a  small  and  well-located  cicatrix. 

Amputation  by  the  Single-flap  Method  (Mal- 
gaigne). — The  method  of  Malgaigne  admits  of 
rapid  execution,  and,  were  it  not  for  the  available 
anaesthetic,  would  be  the  proper  operation  to 
select,  in  view  of  the  additional  shock  caused  by 
the  more  methodical  and  lengthy  procedures 
advocated  elsewhere. 

Having  controlled  the  circulation,  place  the  patient  on  the  table,  with 
the  hip  overhanging  the  edge.  The  surgeon,  standing  at  the  outer  side  of 
the  limb,  which  is  slightly  flexed  and  separated  from  its  fellow,  introduces 


Fig.  670. — Malgaigne's  meth- 
od. A.  Point  of  entrance 
of  knife.  B.  Point  of  exit 
of  knife.  C.  Poupart's 
ligament.  D.  Knife  pass- 
ing through  capsule.  E. 
Trochanter  major. 


556 


OPERATIVE  SURGERY. 


the  point  of  a  long  knife  midway  betAveen  the  anterior  superior  spinous 
process  of  the  ilium  and  the  top  of  the  trochanter  major  (Fig.  661),  di- 
recting it  in  the  course  of  Poupart's  ligament  down  to  the  bones,  when  it 


Fig.  671. — Assistant  compressing  vessels. 

is  carefully  withdrawn  a  little  way,  and  the  handle  is  depressed  sufficiently 
to  permit  the  easy  passage  of  the  point  of  the  knife  across  the  neck  of  the 
femur  and  through  the  anterior  portion  of  the  capsule.  If  the  handle  be 
depressed  before  the  point  is  withdrawn,  the  point  may  be  broken.     The 

handle  is  then  raised  and  the 
knife  pushed  onward  until  the 
point  emerges  an  inch  below 
and  in  front  of  the  tuberosity 
of  the  ischium  (Fig.  670). 
The  flap  is  then  made  by 
carrying  the  blade  downward 
six  to  eight  inches  along  the 
anterior  surface  of  the  bone, 
parallel  with  its  line  of  en- 
trance, when  it  is  brought  di- 
rectly to  the  surface.  Before 
the  vessels  are  divided  an  as- 
sistant seizes  the  flap  by  in- 
serting the  fingers  into  either 
side  of  the  incision  above  the 
knife,  compresses  the  vessels, 
and,    when    these    latter    are 


Fig.  672. — Passing  blade  behind  head  of  bone. 


severed,  carries  the  flap  upward  on  to  the  abdomen   (Fig.    671),    while 
the  surgeon  at   the  same  time   divides  the   remaining  anterior   portion 


AMPUTATION   AT   TIIK   LOWER   EXTREiMlTY.  557 

of  the  capsule  with  the  point  of  the  knife;  another  assistant  then  rotates 
the  thigh  inward,  and  the  attachments  to  the  great  trochanter  are  severed. 
The  limb  is  then  quickly  and  forcibly  rotated  outward  and  abducted,  causing 
the  head  of  the  bone  to  escape  sufficiently  to  expose  the  ligamentum  teres, 
which  is  divided  with  the  point  of  the  knife,  and,  as  the  head  of  the  femur 
slips  from  its  cavity  the  blade  is  passed  behind  the  l)onc  (Figs,  670,  672), 
which  is  seized  with  the  left  hand  of  the  operator,  who  ([uickly  severs  the 
posterior  tissues  by  a  downward  and  inward  stroke  of  the  knife. 

Tli&  After-treatment. — The  combating  of  shock,  the  maintenance  of 
cleanliness  and  good  drainage,  the  proper  support  of  the  flap  during  healing, 
and  the  prevention  of  bedsores,  are  the  chief  requirements  of  this  treatment. 

The  Bcsults. — The  rate  of  mortality  is  governed  by  the  nature  of  the 
cause  calling  for  the  operation.  In  immediate  amputations  in  military  prac- 
tice, ninety-three  per  cent  die.  In  civil  practice,  the  mortality  after  the  pri- 
mary amputations  reaches  eighty  per  cent.  Secondary  amputations  offer 
better  results;  sixty  per  cent  recover  in  the  civil  and  military  combined. 

The  results  are  more  favorable  in  non-traumatic  cases,  the  mortality 
being  less  than  forty-one  per  cent.  Taking  both  traumatic  and  non-trau- 
matic together,  the  rate  is  a  little  over  sixty  per  cent,  being  a  trifle  more 
than  for  amputation  in  the  continuity  of  the  thigh,  which  is  about  sixty- 
three  and  a  half  per  cent.  But  in  civil  practice,  with  antisepsis  and  the 
modern  methods  for  the  control  of  hemorrhage,  the  death  rate  is  only  about 
sixteen  per  cent.  The  transfixion  methods  of  practice  are  much  inferior  to 
the  racket  methods,  and  can  not  be  commended  excej)t  when,  for  some 
special  reason,  the  latter  are  unsuited  for  the  purpose. 

The  Later  Results. — Of  754  cases  of  disarticulation  at  the  hip-joint,  for 
all  causes,  6i6  were  done  before  asepsis,  with  a  mortality  of  82.45  per  cent; 
and  108  done  under  asepsis,  of  which  36.19  per  cent  died. 


CHAPTER  XL 
DEFORMITIES. 

Deformities  may  be  either  congenital  or  acquired,  and  they  affect, 
individually  or  conjointly,  the  soft  or  hard  parts. 

The  acquired  deformities  usually  depend  on  anchylosed  joints,  distorted 
shafts  and  extremities  of  bone,  irregular  or  unequal  muscular  contraction,  etc. 
To  overcome  the  deformities  dependent  upon  anchylosis,  we  resort  to  forcible 
movement,  if  it  be  fibrous ;  and  the  division  of  the  bone  and  to  excision  or 
division  of  the  joint  structure,  if  it  be  bony. 

The  forcible  movement  of  an  anchylosed  joint,  while  not  an  operation  in 
the  accepted  sense  of  the  term,  is  nevertheless  often  associated  with  conse- 
quent complications,  which  entitle  it  to  a  greater  degree  of  prominence  than 
that  of  many  accepted  operative  procedures. 

Brisement  Force,  as  it  is  sometimes  called,  is  a  forcible  breaking  up  of 
an  anchylosed  joint,  and  should  be  preceded  by  subcutaneous  section  of  all 
the  tendons,  muscles,  and  fascia  upon  which  "  point  pressure  "  causes  reflex 
action  (Say re). 

The  incisions  having  healed,  place  the  patient  upon  a  hard  table,  admin- 
ister an  anaesthetic,  and,  while  the  portion  of  the  limb  between  the  anchylosed 
joint  and  the  body  of  the  patient  is  held  firmJy  by  assistants,  the  surgeon 
seizes  the  distal  portion  of  the  limb  and  flexes  it  by  the  employment  of 
steady  and  persistent  force.  As  soon  as  moderate  movement  follows  flexion, 
the  limb  is  then  extended,  and  by  repeated  flexion  and  extension  the  range 
of  motion  of  the  joint  is  cautiously  increased. 

If  the  Tcnee-joint  be  the  one  in  question,  the  patella  must  be  loosened 
before  movement  is  attempted.  After  the  manipulation,  strap  the  toes  and 
bandage  the  limb  from  the  toes  to  the  knee  firmly,  having  first  applied 
adhesive  plaster  to  the  leg  for  the  purpose  of  extension.  Pad  the  popliteal 
space  with  cotton,  and  surround  the  knee-joint  with  strips  of  adhesive  plaster 
firmly  and  symmetrically  applied.  Continue  the  roller  over  the  knee  and 
up  the  thigh,  applying  pressure  to  the  femoral  artery  by  means  of  a  small 
piece  of  moist  sponge  applied  over  its  course  and  held  in  position  by  the 
ascending  bandage  (Sayre). 

The  Remarks. — If  the  anchylosis  le  lony,  the  deformity  can  be  relieved 
bv  osteotomy  above  the  condyles,  and,  if  necessary,  below  the  head  of  the 
tibia  at  the  same  time ;  by  excision  of  the  joint ;  or  by  the  removal  of  a 
wedge-shaped  piece  of  bone  from  the  joint,  as  described  in  Fig.  459.  The 
plan  advised  by  Barton  can  be  practiced  (Fig.  673). 
558 


DEFORMITIES.  559 

For  severance  of  the  anchylosis,  boring  the  joint  and  other  expedients 
have  been  resorted  to.  The  safest  of  all,  however,  is  supra-condyloid  oste- 
otomy (page  444).  In  all  joints,  anchylosis  is  amenable  to  one  or  more  of 
these  procedures. 

In  anchylosis  of  the  knee-joint  of  long  standing,  attended  with  contrac- 
tion of  the  heads  of  the  gastrocnemius  with  or  without  subluxation  of  the 
head  of  the  tibia,  forcible  extension  of  the  leg  fre- 
quently causes  rupture  of  the  attachments  of  the 
muscle  to  the  condyles  of  the  femur,  often  followed 
by  a  degree  of  hsemorrhage  that  suggests  rupture 
of  the  popliteal  vessels.  If  the  tendo  Achillis  be 
divided,  or  the  foot  be  forcibly  extended  before 
extension  of  the  leg  is  attempted,  the  resisting  in- 
fluence of  the  gastrocnemius  will  be  reduced  to  a 
minimum.  At  all  events,  the  foot  must  not  be 
flexed  during  the  manipulation  for  reasons  that 
should  be  obvious. 

During  the  act  of  correction  the  opposing  bands 
of  tissue  are   severed   subcutaneously  as  their  re-    Fig.  673.— Barton's  opera- 
sisting  tension  brings  them   to   notice.      And   it 

should  not  be  forgotten  that  the  contiguous  tense  nerve  trunks  and  vessels, 
especially  the  popliteal  in  rectification  of  the  knee,  may  be  mistaken  for  the 
simpler  structures  and  divided.  If  the  anchylosis  be  of  long  standing,  and 
especially  if  associated  with  subluxation,  proper  rectification  of  the  deform- 
ity may  be  impracticable  or  unsafe,  and  even  impossible.  Impracticable, 
because  of  the  pain,  numbness,  and  loss  of  power  following  undue  stretch- 
ing of  the  nerve  trunks  ;  unsafe,  on  account  of  the  danger  of  rupture  of  im- 
portant vessels,  and  impossible,  for  the  reason  of  the  pronounced  relative 
changes  of  the  hard  and  soft  structures  of  the  joint.  Therefore  a  proper 
consideration  for  the  safety  of  the  patient  and  the  security  of  the  limb 
may  promptly  demand  the  substitution  of  operation  for  manipulative 
rectification. 

Deformities  caused  by  distortion  of  the  long  bones  can  be  best  corrected 
by  osteotomy  (page  443   et  seq.). 

The  After-treatment. — Place  the  patient  in  bed,  employ  extension  of  the 
limb  with  the  foot  of  the  bed  elevated ;  apply  ice-bags  to  the  knee  and  keep 
the  limb  immovably  confined.  At  the  end  of  five  or  six  days  the  dressings 
are  removed,  and,  after  slight  motion  is  made,  replaced,  the  sponge  being 
omitted. 

The  Results. — Loss  of  life  and  of  limb  from  rupture  of  vessels,  from 
severe  inflammatory  reaction,  and  from  fat  embolism  may  follow  incautious 
or  too  vigorous  attempts  at  rectification,  especially  of  large  joints.  If  marked 
chronic  arthritic  changes  be  present  in  the  joint,  correction  with  complete 
anchylosis  or  perhaps  limited  motion  is  all  that  need  be  expected  from  even 
repeated  attempts  at  cure.  The  attainment  of  perfect  motion  need  not  be 
expected,  and  often  complete  relapse  follows  more  or  less  promptly  the  best- 
directed  efforts  for  relief. 


560 


OPERATIVE  SURGERY. 


Curvature  of  the  Spine. — "  A  common  method  of  treatment  at  the  present 
time  is  the  application  of  the  plaster-of- Paris  dressing.  The  body  of  the 
patient  is  surrounded  first  by  a  closely  fitting  knitted  jacket,  between  which 
and  the  region  of  the  stomach  is  introduced  a  wedge-shaped  '  dinner  pad,' 
with  the  point  downward,  composed  of  a 
folded  towel,  or  several  thicknesses  of  cloth, 
or  cotton  wadding  surrounded  by  cloth. 
All  sensitive  parts  and  projecting  points 
should  be  relieved  from  direct  pressure  by 
spongio-piline,  cotton,  felt,  or  other  similar 


Fig.  674. — Apparatus  applied. 


Fig.  675.— Body  extended, 


material.  The  iliac  spines,  the  adjoining  portions  of  the  iliac  crests,  and 
the  mammary  glands  in  the  female  should  also  be  protected : 

"  Suitable  space  for  the  latter  should  be  provided  by  the  introduction  of 
properly  shaped  pads. 

"  Tie  the  shirt  over  the  shoulders  and  fasten  it  between  the  legs.  Then 
the  patient  is  drawn  up  by  the  extending  apparatus  (Fig.  674),  gently  and 
slowly  until  he  feels  perfectly  comfortable,  and  never  beyond  that  point 
(Fig.  675).  A  prepared,  saturated  plaster-of-Paris  roller  having  been  gently 
squeezed,  so  that  all  surplus  water  is  removed,  is  now  applied  around  the 
smallest  part  of  the  body,  and  is  carried  round  and  round  the  trunk,  down- 
ward to  the  crest  of  the  ilium,  and  a  little  beyond  it ;  afterward  in  a  spiral 
direction  from  below  upward,  until  the  entire  trunk  from  the  pelvis  to  the 
axillffi  has  been  incased. 

"  The  bandage  should  be  placed  smoothly  round  the  body,  and  must  not 
be  drawn  tight ;  it  should  be  simply  unrolled  with  one  hand  while  the  other 


DEFORMITIES. 


5fil 


Fig.  676. — Sayre's  jury-mast 
head-swing. 


follows  and  brings  it  into  smooth,  close  contact  with  all  irregularities  of  the 
trunk. 

"  After  one  or  two  thicknesses  of  bandage  have  been  placed  around  the 
body  in  the  manner  described,  narrow  strips  of 
roughened  or  perforated  tin  can  be  placed  parallel 
with  each  other  on  either  side  of  the  spine,  or, 
if  the  case  requires  it,  at  intervals  of  two  or  three 
inches  in  sufficient  number  to  surround  the  body. 
Over  these  another  plaster  bandage  is  applied. 
In  a  very  short  time  the  plaster  sets  with  suf- 
ficient firmness,  so  that  the  patient  can  be  removed 
from  the  suspending  apparatus,  and  laid  upon 
the  face  or  back  on  a  hair  mattress,  or,  what  is 
preferable,  especially  when  there  is  much  pro- 
jection of  the  spinous  processes  or  sternum,  an 
air  bed.  Before  the  plaster  has  completely  set, 
the  '  dinner  pad '  is  removed,  and  the  plaster 
gently  pressed  in  with  the  hand,  in  front  of 
each  anterior  iliac  spinous  process,  for  the  pur- 
pose of  molding  the  case  over  the  bony  projec- 
tions. 

"  While  the  jacket  is  drying  it  is  necessary 
sometimes  to  wet  it  with  a  little  water  and  dust 
it  with  more  plaster.    The  surgeon  often  leaves  some  weak  spots  that  need 
strengthening  in  this  manner. 

"  If  the  deformity  be  located  in  the  upper  dorsal  or 
in  the  cervical  regions,  the  splint  will  be  inadequate  for 
the  purpose,  and  the  'jury-mast'  (Fig.  676)  should  be 
incorporated  with  it,  and  thereiifter  so  attached  to  the 
head  and  regulated  as  to  relieve  the  spine  of  its  burden 
(Fig.  677)." 

The  preceding  is  a  description  as  recorded  by  Dr. 
Sayre,  to  whom  the  profession  is  indebted  for  the  prom- 
inence which  has  been  given  this  method. 

The  Deformities  dependent  upon  Perverse  Muscular 
Action  are,  in  an  operative  sense,  relieved  by  subcu- 
taneous division,  called  myotomy  and  tenotomy;  the 
latter  has  been  already  considered  (Chapter  IV). 

Torticollis  (Wryneck). — The  operative  treatment  of 
congenital  wryneck  is  directed  to  subcutaneous  or  open 
division  of  the  sterno-mastoid  muscle  and  restraining 
fascial  bands.  The  former  method  of  procedure  has 
already  been  described  (page  338).  The  open  method  is 
practiced  under  strict  antiseptic  precautions,  and  con- 
sists of  dividing  the  sterno-mastoid,  near  its  lower  ex- 
FiG.  677.— Jury-mast  tremity,  from  without  inward,  while  on  the  stretch, 
apparatus  applied.      Eestraining  bands  of  fascia  are  divided  at  the  same 


562 


OPERATIVE   SURGERY. 


time.  After  the  arrest  of  hsemorrhage  the  incision  is  closed,  the  deformity 
rectified,  and  the  head  held  in  an  overeorrected  position  by  a  plaster-of-Paris 
bandage  or  other  suitable  means  until  cure  is  effected. 

The  Remarks. — The  open  method  gives  good  results,  but  has  limited  ap- 
plication. The  care  needed  to  avoid  injury  of  the  underlying  important 
structures  is  apparent.  Other  cervical  muscles  preventing  rectification  can 
be  divided,  if  not  too  deeply  located ;  then  their  opposition  can  be  overcome 
by  forcible  restitution  under  anaesthesia. 

Spasmodic  wryneck  is  treated  by  resection  of  the  spinal  accessory  nerve 
(page  319),  and  of  the  posterior  divisions  of  the  cervical  nerves  (page  320). 
The  latter  are  divided  in  instances  of  post-cervical  muscular  spasm  and  after 
failure  from  division  of  the  spinal  accessory. 

The  Remarks. — The  results  from  section  of  the  spinal  accessory  are  quite 
fiattering.  Of  twenty-six  cases  thus  treated  by  Petit,  thirteen  were  a  "  per- 
fect success,"  seven  much  improved, 
two  but  slightly  benefited,  three  tem- 
porarily benefited.  This  operation  is 
not  so  highly  regarded  as  formerly. 

Hammer-toe  (Fig.  678). — The  de- 
formity is  indicated  with  sufficient 
accuracy  by  the  illustration.  In  the 
majority  of  instances  the  second  toe 
is  affected,  and  when  surmounted 
with  a  painful  corn  is  exceedingly 
annoying.  Two  or  three  methods  of 
treatment  are  practiced,  depending 
on  the  obstinacy  of  the  case :  1.  For- 
cible reposition  with  the  fingers, 
aided,  if  necessary,  by  a  V-shaped 
division  of  the  shortened  skin.  2. 
Subcutaneous  division  of  the  lateral 
and  glenoid  ligaments,  and  even  the 
flexor  tendons  when  required. 

The  division  is  accomplished  by 
means  of  a  narrow-pointed  strong-backed  knife  (Fig.  368),  the  point  being 
entered  at  the  center  of  the  under  surface  opposite  to  the  first  interphalangeal 
joint  and  carried  upward  beneath  the  skin,  avoiding  the  digital  arteries 
and  nerves  (Fig.  227).  Sever  the  lateral  and  the  glenoid  ligaments,  and 
divide  the  long  tendon  without  removal  of  the  knife,  if  required.  Kow, 
complete  restoration  can  usually  be  accomplished  with  but  little  effort.  A 
failure  in  the  attempt  is  followed  by  the  employment  of  other  means  in 
turn,  such  as  division  of  the  extensor  tendon,  excision  of  the  head  of  the 
bone,  and  even  of  the  entire  joint.  Amputation  need  not  be  considered 
if  the  foregoing  expedients  can  be  carried  into  effect  properly. 

Mallet-finger  (Fig.  679). — This  deformity  results  from  a  blow  upon  the 
end  of  the  finger,  and  is  a  sequel  of  changes  in  the  joint  and  contiguous 
tissues  due  to  gout.     In  the  former  instance  the  points  of  attachment  of 


Fig.  678.— Hammer-toe, 


DEFORMITIES. 


5fi3 


the  extensor  tendon  to  the  phalanx  are  partially  or  completely  torn  asunder, 
or  stretched,  or  thinned  by  separation.  In  the  latter,  stretching  is  the  prin- 
cipal element  of  the  cause  of  the  deformity.  Eepair  can  be  effected  by 
exposure  of  the  extensor  tendon  at  the  dorsum  of  the  distal  phalanx  through 
a  longitudinal  incision  about  three  quarters  of  an  inch  in  length.  The  ten- 
don is  raised,  divided  transversely  at  its  thinnest  portion,  shortened,  and 
the  proximal  end,  advanced  so  as  to  overcome  the  deformity,  is  stitched 
to  the  under  surface  of  the  skin  near  to  the  root  of  the  nail.  The  wound  is 
closed  and  the  finger  confined  until  repair  has  taken  place.  The  end  of  the 
tendon  becomes  fixed  to  the  skin  and  also  to  the  underlying  periosteum  ;  if 
moderate  overcorrection  be  secured  at  the  outset  the  final  result  will  be 
correspondingly  improved. 

Snap-finger. — This  expression  refers  to  an  interrupted  extension  of  a 
finger,  often  requiring  aid,  and  attended  with  an  evident  snap  or  jerk  of  the 
finger  Avhen  the  obstruction  is  overcome.  After  passive  motion  fails  to  cure 
this  infirmity,  any  abnormality  associated  with  the  tendons  or  with  their 
synovial  structures  contributing  to  the  trouble,  should  be  approached  and 
treated  through  a  free  incision,  and  under  strict  antisepsis. 


Fig.  679.— 3IallL4-finffer. 


Fig.  680. — Supernumerary  digits. 


Deformities  due  to  Fusion  of  the  parts  and  supernumerary  attachments, 
like  webbed  fingers  and  toes,  and  supernumerary  digits,  although  not  com- 
mon, are  nevertheless  entitled  to  consideration. 

Polydactylism  (Supernumerary  Finger). — One  meets  occasionally  with  a 
case  bearing  an  extra  finger,  usually  located  at  the  radial  side  of  the  thumb 
or  the  ulnar  side  of  the  little  finger  (Fig.  680).  Bone  is  usually,  although 
not  necessarily,  present  in  these  abnormalities.  They  should  be  removed 
early,  and  with  strict  antisepsis,  because  not  infrequently  the  synovial  cav- 
ities of  the  normal  are  intimately  associated  with  those  of  the  attached  ex- 
tremities of  the  abnormal  digits.     Supernumerary  toes  are  similarly  treated. 

Syndactylism  (Webbed  Fingers). — The  operative  treatment  for  the  relief 
of  this  deformity  will  depend  very  much  indeed  on  the  extent  as  well  as  the 
thickness  of  the  attachments;  whether  the  connections  be  limited  to  the 
soft  parts  alone,  or  the  bones  be  fused.  Digits  that  are  united  by  their 
extremities  only  can  be  separated  easily  by  the  division  of  the  tissues  which 
connect  them.    If  they  be  united  the  entire  length,  even  then  an  incision  in 


564 


OPERATIVE  SURGERY. 


the  median  line  of  their  attachments,  down  to  the  line  of  the  normal  web, 
may  be  sufficient  to  effect  a  cure,  if  the  tissues  connecting  them  be  not  too 
thick;  if  such  be  the  case,  great  difficulty  is  often  experienced  in  healing 
the  divided  surfaces,  owing  to  the  tendency  to  reunion  at  the  point  of  junc- 
tion. To  obivate  this,  various  expedients  have  been  recommended,  one  of 
which  (Eudtlorffer)  is  to  introduce  a  rubber  seton  at  the  base  of  the  mal- 
formation on  a  line  with  the  normal  web  of  the  hand,  and  allow  it  to  remain 
until  the  opening  becomes  permanent  (Fig.  681),  when  the  remaining 
portion  is  divided  and  the  borders  united  by  sutures.  The  employment  of 
a  lead,  silver,  or  gold  button  has  been  practiced  with  a  similar  outcome. 
Another  plan  (Dec)  is  to  make  a  short  triangular  flap  of  the  entire  thickness 
of  the  web  at  its  posterior  portion,  the  base  corresponding  in  shape  and  size 
to  the  space  between  the  knuckles,  and  the  apex  directed  to  the  free  edge  of 
the  abnormal  attachment.  The  flap  is  raised  and  turned  aside,  the  fingers 
kept  widely  separated,  until  the  cicatrization  of  the  flap  is  followed  by 


Webbed  fingers. 


. — Norton's  operation. 


retraction  and  formation  of  a  new  commissure.  The  remaining  portion 
of  the  web  is  then  divided  and  the  borders  of  the  wound  are  closed  by 
sutures  as  in  other  instances.  This  method  is  well  suited  for  the  treatment 
of  wide-webbed  cases. 

Norton  suggested  the  making  of  two  well-nourished  flaps  at  the  base  of 
the  phalanges — one  on  the  palmar  and  one  on  the  dorsal  aspect — followed 
by  severance  of  the  webbed  tissue  between  them  up  to  the  base  of  the  flaps 
(Fig.  682).  The  flaps  are  then  united  with  each  other  by  flne  sutures,  and 
the  fingers  are  kept  well  apart  during  healing. 

Another  very  effectual  and  ingenious  method,  devised  by  Diday  (Fig. 
683),  is  thus  described  by  M.  JSTelaton :  "  A  longitudinal  incision  is  made  in 
the  center  of  the  phalanx  of  one  finger  on  the  dorsal  aspect  for  the  posterior 
flap  (a  h) ;  on  the  palmar  aspect  of  the  other  for  the  dorsal  flap  (c  d) ; 
the  length  of  the  incision  will  correspond  with  the  depth  of  the  web.  From 
either  extremity  of  the  longitudinal  incision,  a  small  transverse  one  is  to  be 


DEFORMITIES. 


565 


made  toward  the  phalanx  of  the  connected  finger  (Fig.  683).  The  lower 
transverse  incision  will  correspond  to  the  free  edges  of  the  web;  the  upper 
one  will  cross  the  flap  between  the  fingers.  Each  flap  is  now  to  be  dissected 
.back  toward  the  contiguous  fingers.     In  doing  this  the  two  folds  of  the 


Fig.  683. — Diday's  operation. 

web  will  be  separated  from  each  other,  one  entering  into  the  formation  of 
the  posterior  flap,  the  other  into  the  formation  of  the  anterior.  Each  flap 
will  now  be  found  to  be  attached  by  one  edge  only,  and  is  to  be  wrapped 
around  the  denuded  surface  of  the  finger  to  which  it  is  attached  (e).  The 
flaps  are  to  be  adjusted  by  strips  of  adhesive  plaster  and  by  sutures." 

Annandale  says:  "The  principal  objection  to  this  ingenious  operation 
appears  to  me  to  be  that  it  necessitates  cutting  into  the  palmar  and  dorsal 
aspects  of  the  fingers  in  order  to  get  a  flap  to  cover  their  sides."  If  the  web 
or  fold  of  the  skin  be  loose,  he  deems  it  preferable  "  to  make  the  longitudinal 


Fig.  684. — Agnew's  operation. 


Fig.  685. — Zeller's  operation. 


incision  along  the  sides  of  each  finger  instead  of  along  the  center  of  the 
dorsal  and  palmar  aspects."  Diday's  method  is  objected  to  also  on  the 
ground  that  the  web  may  be  too  thin  to  admit  of  splitting  without  danger 
of  sloughing,  and  that,  in  spite  of  every  care,  the  granulating  process  may 


566 


OPERATIVE  SURGERY. 


involve  the  cleft  and  cause  renewal  of  the  deformity;  also  that  flexion  and 
extension  of  the  fingers  may  be  crippled  if  the  flaps  be  ill-fitting.  If  Diday's 
operation  be  performed,  care  must  be  taken  in  uniting  the  flaps  or  slough- 
ing will  ensue. 

Agnew's  Method  (Fig.  684). — Eaise  from  the  dorsal  surface  of  the  base  of 
the  web  a  triangular-shaped  flap,  with  the  apex  forward,  comprising  half 
the  thickness  of  the  web;  divide  the  remaining  portion  of  the  web  longi- 
tudinally ;  carry  the  flap  through  the  cleft  at  the  base  of  the  flngers ;  stitch 
its  apex  and  its  borders  to  the  wound  of  the  palm  and  the  sides  of  the 
flngers  respectively;  separate  and  immobilize  the  flngers  while  healing 
takes  place. 

Zeller's  Method  (Fig.  685). — Make  two  incisions  on  the  dorsal  aspect  of 
the  web  and  flngers,  beginning  respectively  at  the  metacarpo-phalangeal 
joints  (a  &)  and  ending  at  a  common  point  in  the  middle  of  the  web  (c), 
opposite  the  second  (surgical)  interphalangeal  joints;  reflect  the  triangular 
flap  thus  formed  and  divide  the  remainder  of  the  web  (c  d) ;  separate  the 
flngers  widely  and  carry  the  flap  (e)  between  them,  and  join  it  with  the 
borders  of  the  cleft  and  the  wound  of  the  palm.  Keep  the  raw  surfaces 
widely  separated  during  healing. 

Fowler  advocates  an  original  proposition  (Fig.  686)  for  the  relief  of 
severe  and  intractable  cases  in  the  following  words :  "  Dissect  up  two  nar- 
row flaps  from  the  back  of  the  hand  (&^  h^)  and  pass  them  through  a  button- 
holelike slot  previously  made  in  the  line  of  the  natural  web  (a^  a^),  and 
well  up  between  the  heads  of  the  metacarpal  bones.     If  for  a  single  web, 


Fig.  686. — Fowler's  operation.    Formation 
of  flaps  and  buttonholes. 


Fig.  687. — Fowler's  operation.    Flaps 
passed  through  buttonholes. 


'  place  the  flaps  with  the  skin  surfaces  facing  each  other,  rotate  each  flap 
slightly,'  and  pass  them  through  the  buttonhole  so  as  to  project  a  quarter  of 
an  inch  or  more  on  the  palmar  surface.  The  extremity  is  pinned  to  the 
palm  as  no  sutures  are  needed.  At  the  end  of  a  week  divide  the  web,  and 
a  '  healthy  integumentary  tissue '  will  be  found  to  occupy  the  cleft.  If  a 
double  web  be  present,  each  flap  can  be  thrust  through  the  slit  correspond- 
ing to  it.     The  wound  on  the  dorsum  (Fig.  687)  is  closed  at  once  and 


DEFORMITIES. 


567 


Anger's 
C.  Cot- 


dressed;  the  bases  of  the  flaps  arc  divided  when  the  weh  is  severed.     The 
wound  is  treated  aseptically  tlirougliout." 

The  Remarks. — When  the  joints  of  tlic  digits  are  fused,  it  is  not  wise,  as 
a  rule,  to  attempt  their  separation,  since,  though  it  may  be  accomplished, 
the  digits  when  separated  may  have  their  function  greatly  impaired;  how- 
ever, this  course  of  action  is  not  so  objectionable  since 
the  advent  of  asepsis.  If  a  supernumerary  digit  pos- 
sesses an  independent  articulation,  it  can  be  removed 
without  any  great  danger  to  its  associate. 

Ingrown  Toe  Nail. — Ingrown  toe  nail  is  quite  a  com- 
mon affliction,  to  the  relief  of  which  various  palliative 
measures  have  been  directed  (Fig.  688).  As  a  rule, 
however,  they  have  been  found  inadequate  to  effect 
a  cure.  This  condition  is  induced  largely  by  improp- 
erly fitting  boots  and  shoes,  although  in  some  persons 
there  exist  additional  causes.  Going  barefooted  will  in 
a  majority  of  cases  effect  a  cure,  but,  since  this  is  rarely 
practicable,  operative  measures  are  often  necessary. 

The  Operation. — When  the  affliction  is  fully  estab- 
lished, administer  an  anaesthetic,  and  with  a  sharp- 
pointed  scalpel  divide  the  nail  at  the  side  its  entire 
length  on  a  line  parallel  with  its  ingrown  border  (+'), 
which  latter  can  then  be  quickly  and  easily  removed  by 
a  thin-bladed  forceps  or  a  narrow  spatula  passed  beneath 
it.  If  the  other  border  be  affected,  it,  too,  should  be 
removed  in  a  similar  manner.  Cauterize  the  exposed  matrix  back  to  the 
limit  of  the  root,  and  apply  a  hot  aseptic  anodyne  poultice  at  once.  The 
patient  must  keep  quiet  until  the  tenderness  has  in  a  measure  subsided.  In 
no  instance  ought  the  entire  nail  to  be  removed  unless  it  be  diseased. 

The  method  just  described  is  somewhat  old-fashioned,  and  although 
satisfactory  as  far  as  final  relief  is  concerned,  still  the  cure  is  protracted, 
and  the  final  outcome  less  gratifying  than  with  the  modern  and  more  sci- 
entific methods  of  procedure. 

Anger's  Method. — Inject  into  the  diseased  site  twenty 
or  thirty  drops  of  a  two-per-cent  solution  of  cocaine, 
having  previously  encircled  the  toe  with  rubber  tubing 
to  limit  the  action  of  the  cocaine  and  control  hemor- 
rhage. Beginning  above  the  upper  limit  of  the  matrix 
(dotted  line),  split  the  nail  longitudinally,  close  to  the 
diseased  margin  (-[-)  with  a  sharp  knife;  remove  the 

ing  a  bed  tissue  fragment  of  nail  with  forceps;  dissect  away  the  diseased 

removed  at  matrix.  /  -s     .      i     t  ^  ,t^ 

w.  Wedge-shaped  parts  (.4 ),  including  the  exposed  matrix  (Fig.  688),  even 

scraping  the  periosteum  from  the  bone  at  that  situation 

(Dowd);  bring  the  borders  of  the  wound  together  (Fig. 

690)  with  horsehair;  dress  antiseptically,  and  keep  the  limb  quiet  for  two 

or  three  days.     Or  the  diseased  soft  parts  can  be  removed  with  a  knife, 

transfixing  vertically  at  the  posterior  limit  of  the  exposed  matrix  all  of  the 


Pig.  688.—^ 
operation, 
ting's  operation. 
+'.  Earlier  method. 
Dotted  line,  the 
limits  of  matrix. 
-h .  Tissues  removed 
in  Anger's  opera- 
tion. 


Pig.     689.  —  Trans- 
verse section  show- 


removal.     C.   Cot- 
ting's  operation. 


568 


OPERATIVE  SURGERY. 


Fig.  690.— Anger's 
operation  com- 
pleted. 


tissues^  followed  by  their  complete  anterior  division  along  the  side  of  the 
phalanx.  The  diseased  portion  of  the  flap  thus  formed  and  the  exposed 
matrix  (a  h  c  d)  are  carefully  dissected  away  and  the 
wound  closed  and  treated  as  before. 

The  Remarhs. — The  chief  aim  of  this  method  is  the 
complete  removal  of  the  matrix,  to  obviate  the  disfigure- 
ment and  annoyance  that  might  follow  the  development 
of  homy  growths.  The  removal  of  a  thin  portion  of  the 
underlying  bone  is  sometimes  practiced  to  insure  success 
in  this  regard.* 

The  Results. — Dowd  reports  twenty-three  cases  that 
were  under  his  observation  for  periods  of  twelve  days  to 
twelve  months,  and  in  all  but  one  the  result  was  entirely 
satisfactory.  Dr.  Dowd's  subsequent  experience  equals 
in  number  and  conforms  in  results  to  the  preceding,  so 
far  as  he  can  now  determine. 

Cotting  sliced  off  together  the  healthy  and  affected 
tissues  down  to  the  margin  of  the  nail,  and  allowed  the 
wound  to  heal  by  granulation  (Fig.  688,  c). 

Cases  in  which  the  anterior  portion  of  the  nail  only  is  at  fault  can  be 
treated  by  the  removal  of  a  wedge-shaped  piece  (Fig.  689,  w)  of  the  soft 
parts  from  the  side  of  the  toe  and  the  closure  of  the  wound  with  sutures, 
thus  drawing  the  inflamed  tissue  away  from  the  border  of  the  nail.  In  this 
method  special  care  must  be  taken  to  avoid  infection  of  the  fresh  wound. 

Bunion. — A  bunion  is  accompanied  in  a  large  proportion  of  cases  by 
malposition  of  the  great  toe  (Fig.  691),  and  increase  in  the  size  of  the 
normal  bursa,  or  the  development  of  an  adventitious 

one.    The  simpler  operative  means  for  relief  consist  l^%„ 

either  in  the  excision  of  the  bursa  or  its  subcu- 
taneous division  with  a  narrow  tenotome.  If  these 
means  fail,  a  sufficient  amount  of  bone  should  be 
excised  to  allow  the  return  of  the  toe  to  its  normal 
position.  The  operation  described  on  page  408  can 
be  performed  in  such  cases,  after  which  the  toe  is 
conflned  in  place  until  recovery  is  established. 

The  Remarhs. — Since  free  communication  be- 
tween the  bursa  and  the  joint  cavity  is  often  pres- 
ent, the  former  should  be  invaded  only  with  strict 
antiseptic  precautions.     It  is '  sometimes  necessary 

to  sever  the  attachments  of  the  bone  at  the  flbular  side  of  the  second  (surgi- 
cal) phalanx  before  proper  rectification  can  be  satisfactorily  maintained,  even 
after  quite  free  excision. 

*  If  bleeding  happen,  Horsley's  wax  may  be  applied.  Horsley's  wax  is  composed  of 
seven  parts  of  bee's  wax  and  one  each  of  sweet  oil  and  salicylic  acid.  It  should  be  kept 
in  a  wide-mouthed  jar  under  a  solution  of  carbolic  acid.  It  is  pinched  off  and  kneaded 
for  use  when  required. 


Fig.  691.— Bunion  with 
hallux  valgus. 


CHAPTER  XII. 

PLASTIC  SURGERY. 

Plastic  surgery  relates  to  the  means  adopted  to  overcome  or  alleviate 
the  deformities  of  aspect  and  function  resulting  from  congenital  defects, 
disease,  or  accident,  by  the  utilization  of  living  tissue. 

Inasmuch  as  the  successful  issue  of  these  operations  depends  far  more  on 
the  careful  attention  to  the  details  and  small  matters  connected  with  them 
than  anything  else,  it  is  well  for  the  operator  to  understand  at  once  that 
there  is  no  precaution  so  trifling  as  to  be  treated  with  indifference. 

The  Preparation  of  the  Patient. — The  patient  ought  to  be  in  a  vigorous 
physical  condition,  the  appetite  and  functions  normal,  and  the  surround- 
ings of  such  a  character  as  to  combine  quietude  of  mind  with  close  and 
gentle  attention.  No  association  can  be  allowed  with  putrefactive  processes, 
or  diseases  known  to  engender  changes  derogatory  to  union  and  repair. 
Prior  to  the  operation,  the  part  should  be  purified  by  well-recognized  aseptic 
measures. 

The  Size  of  the  Flap. — The  shape  and  size  of  the  flap  must  be  ascertained 
by  careful  measurement.  A  pattern  of  the  deformity  to  be  repaired  is  care- 
fully cut  out  and  used  to  outline  the  flap  employed  in  filling  the  gap. 
The  contraction  of  the  normal  tissues,  when  loosened  from  their  underlying 
attachments,  may  be  sufficient  to  require  undue  force  to  secure  proper  coap- 
tation of  the  divided  borders.  Therefore,  reparative  flaps  should  always  be 
made  large  enough  to  admit  of  at  least  four  lines  of  shrinkage  for  each  inch 
in  width  of  their  surface. 

The  flap  should  be  formed  of  sound,  healthy  skin,  and  under  no  con- 
sideration should  cicatricial  tissue  of  a  pale,  glossy  surface  be  employed, 
for  when  its  subcutaneous  connections  are  severed,  it  is  almost  certain  to 
slough,  especially  when  the  result  of  a  burn.  The  relation  which  cicatricial 
tissue  bears  to  a  flap  is  all-important.  If  it  exists  at  the  base,  sloughing  is 
quite  likely  to  occur.  Cicatricial  tissue  at  the  border  of  a  flap  is  quite  cer- 
tain to  die,  and  its  presence  there  must  not  be  estimated  in  computing  the 
area  of  the  new  flap.  When  the  flap  is  to  be  joined  on  three  sides  with 
cicatricial  formation,  the  base  must  be  made  large,  be  highly  vascular,  and 
but  little  twisted,  as  the  vascular  supply  at  the  sides  will  be  very  little 
added  to  by  the  new  association.  The  thickness  of  the  flap  should  be  suffi- 
cient to  include  all  the  vessels  that  normally  afford  it  nourishment.  The 
long  axis  of  the  flap  should  correspond  to  the  course  of  its  vascular  supply, 
38  569 


5Y0 


OPERATIVE  SURGERY. 


and  the  base  must  be  located  as  nearly  as  possible  to  these  vessels.  Hfemor- 
rhage  must  be  checked  before  the  flaps  are  united^  since  an  intervening  thin 
clot  of  blood  may  prevent  union.  The  direction  of  the  flap  should  be  such 
that  it  can  be  properly  placed  with  the  least  twisting  of  the 
pedicle.  The  edges  of  flaps  may  be  beveled ;  this  increases  the 
width  of  the  opposed  surfaces,  and,  when  combined  with  under- 
cutting of  the  borders,  increases  the  chances  of  union.  Silk- 
worm gut  and  horsehair  make  efficient  sutures,  and  should  not 
be  drawn  tightly.  Carbolized  cotton  yarn  (Buck),  in  connec- 
tion with  the  plastic  pins,  offers  a  soft  and  otherwise  admira- 
ble retaining  agent  when  frequently  changed.  To  avoid  any  danger  of 
ulceration  at  the  pressure  points  small  squares  of  aseptic  carbolized  unglazed 
bibulous  paper,  of  a  diameter  of  half  an  inch  or  so  (Fig.  692),  with  a  small 
hole  through  the  center  of  each,  may  be  used  beneath  the  knots  (Fig.  693). 


Fig.  693.— Pa- 
per protective, 


lIMlLllllllmllllllulllllillllillliiUlii  lliii.l  illililniil  ,1  'lIlhiHuiiilllliilui  llllllJ  1 1 ,11  IIMh  M  Ml 

Fig.   693. — Instruments  employed  in  plastic  surgery. 
Small  scalpel  and  bistoury,     b.  Thumb  forceps,     c.  Thiersch's  forceps,     d.  Mouse- 
tooth  forceps,     e.  Curved  sharp-pointed  scissors.     /.   Curved  and  straight  blunt- 
pointed  scissors,    g.  Forcipressure.     h.  Tenacula.    *.  Black  pins.    k.  A  McBurney 
traction  hook.     I.  Tape  measure,    m.  Razor  for  cutting  skin  grafts. 


PLASTIC  SURGERY. 


571 


If  small  black  pins  (i)  be  inserted  to  indicate  the  extent  of  the  flaps, 
the  incisions  will  be  formed  more  accurately  than  if  they  be  measured  by  the 
aid  of  the  eye  alone.  Flaps  can  be  applied  at  once  to  the  gap  or  allowed  to 
remain  in  sihc,  surrounded  with  proper  dressing,  until  the  vitality  is  tested 
by  the  capacity  of  the  base  to  properly  nourish  them.  Migratory  flajis  are 
sometimes  necessary  to  meet  the  demands  of  scanty  contiguous  integumen- 
tary supply.  A  migratory  flap  is  one  transferred  to  a  prepared  site  located 
nearer  to  the  final  one  than  is  the  seat  of  removal.  As  soon  as  the  flap  is 
properly  united  at  this  place,  the  position  is  again  changed  to  another  still 
nearer  the  site  of  final  lodgment,  and  maintained  either  through  the  preser- 
vation of  the  primary  pedicle  or  the  formation  of  a  new  one,  depending  on 
the  requirements  of  the  case. 

The  Methods  of  Transfer. — The  methods  of  transfer  may  be  classified  into 
six  general  forms,  with  their  subdivisions :  1.  Sliding  in  a  direct  line.  2. 
Sliding  in  a  curved  line.  3.  Jumping.  4.  Inversion,  or  eversion.  5.  The 
Taliacotian.     6.  Grafting. 

Sliding  in  a  Direct  Line. — Four  varieties  characterize  this  method  of 
transfer.  The  first  and  simplest  variety  consists  in  uniting  the  lips  of  an 
ordinary  incision  made  for  the  purpose  of  repair  of  adventitious  openings 
in  the  skin,  and  of  the  simplest  forms  of  harelip,  and  is  sometimes  called 
"  simple  approximation  of  divided  surfaces." 

The  second  variety  is  called  "  undercutting,"  and  consists  in  cutting 
under  the  edges  of  an  incision  at  each  side  before  drawing  them  together. 
This  method  is  employed  in  the  adjustment  of  the  borders  when  undue 
traction  attends  their  union. 

The  third  variety  consists  in  sliding  in  a  direct  line  by  aid  of  parallel 
incisions  made  at  both  sides  of  the  primary  one,  which  is  finally  closed.    The 


45 


Fig.  694.— a.  The  defect,  parallel 
incision,  h.  Closure,  sliding 
in  direct  line. 


Fig.  695.— Transverse 
liberating  incision. 


'till 


TTTT 


Fig.  696.— Opening 
closed. 


outside  incisions  are  allowed  to  heal  by  granulation  (Fig.  694).  Undercut- 
ting at  the  primary  incision  lessens  the  tendency  to  separation  of  the  par- 
allel ones. 

Ill  the  fourtli  variety  the  liberating  incisions  are  made  transversely 
— that  is,  at  right  angles  to  the  extremities  of  the  defect,  or  in  the  long 
axis  of  it,  and  undercutting  is  employed  freely  (Fig.  695)  to  permit  closure 
of  this  opening  (Fig.  696).  The  uppermost  curve  is  undercut,  and  the  low- 
ermost is  lilierated  by  a  coml)ination  of  undercutting  and  sliding  aided  by 
transverse  incisions.     The  defect  at  c  d\s>  repaired  by  making  incisions  at 


572 


OPERATIVE   SURGERY. 


either  end  of  the  defect  in  the  line  of  its  long  axis,  and  raising  and  bring- 
ing together  at  a  &  and  c  d  the  flaps  e  a  c  f  and  e'  h  d  f.  After  further 
sewing  the  wound  appears  as  in  the  illustration.    The  employment  of  two 


Fig.  697. — Repair  by  incisions  in  the  long  axis  of  the  defect. 

flaps  for  a  definite  purpose  lessens  correspondingly  the  demands  that  would 
be  made  on  a  single  flap  for  a  similar  intent. 

Sliding  in  a  Curved  Line. — Sliding  in  a  curved  line  can  be  done  with 
flaps  having  either  curved  or  angular  borders.    In  the  former  instance,  the 


Fig.  698. — DiefEenbach's   bilateral-flap 
method. 


Fig.  699. — Dieffenbach's  bilateral-flap 
method,  defect  closed. 


space  from  wliich  the  flap  is  taken  is  fllled  by  undercutting  and  drawing 
together  the  borders.  In  the  latter,  the  space  is  usually  allowed  to  close 
by  granulation.  This  method  of  repair  is  directed  especially  to  the  closure 
of  triangular,  quadrilateral,  and  elliptical  openings  in  the  integument.    The 


Fig.  700.— Dieffenbach's  unilateral-  Fig.  701.— Euro w's  method, 

flap  method. 

triangular  openings  are  readily  closed  by  Dieffenbach's,  Burow's,  or  Jaesche's 
method.  Dieffenhacli  practiced  two  methods  of  closure,  one  a  bilateral 
(Figs.  698  and  699),  and  the  other  a  unilateral  (Fig.  700)  incision  and 


PLASTIC  SURGERY. 


573 


sliding  method,  in  both  of  which  the  resulting  triangular  spaces  were 
allowed  to  heal  by  granulation.  The  technique  of  these  methods  is  plain 
enough  without  special  comment.  The  flap  a  b  c  d  is  dissected  from  the 
sides  e  d  and  h  c,  slid  across  and  united  with  the  side  a  c,  leaving  the 
triangular  space  h  e  d  to  heal  by  granulation. 

Burow's  method  of  closure  of  a  large  triangular  opening  is  ingenious 
(Fig.  701).  It  consists  in  making  lateral  incisions  d  a  and  h  d',  each  equal 
in  length  to  at  least  two  thirds  of  the  width  of  the  portion  of  the  triangle  to 


Fig.  702. — Burow's  method, 
flaps  united. 


Fig.  703.— Jaesche-Dieffen- 
bach  method. 


9. 


Fig.  704.  — Litten- 
neur's  method. 


which  they  correspond.  The  flaps  d  a  c  and  c  h  d'  are  dissected  up  freely 
and  united  with  each  other  (a  c  to  h  c) .  This  union  causes  great  relaxation 
of  tissue  at  either  side  (a  d  e  and  h  e'  d'),  which  tissue  is  removed  and  the 
borders  properly  joined  with  sutures  forming  the  outlines  of  Fig.  702. 

Jaesclie-Dieffenhacli  Method  (Fig.  703). — The  figure  of  this  method 
explains  fully  the  manner  of  its  application.  If  the  incision  h  d  (Jaesche) 
be  carried  downward  and  to  the  right  h  e,  parallel  with  the  border  h  c  (Dief- 
fenbach),  thereby  forming  flap  c  h  d  e,  and  the  flap  be  dissected  up  and  slid 
to  join  ah  c,  the  gap  will  be  readily  closed. 

Littenneur's  method  of  closure  of  quadrilateral  spaces  by  the  curved 
sliding  process  is  as  follows  (Fig.  70-i)  :  The  flap  b  e  f  g  is  raised  and  slid 
so  that  the  borders  e  f  and  a  d  are  united  with  each  other. 


Ht^ 


e/ii 


Fig.  705. — Briins's  method. 


1 1  n  [  1 

Fig.  706. — Briins's  method,  flaps  united 


Briins's  method  of  closure  with  two  lateral  flaps  is  more  complex  (Fig. 
705).  In  this  the  flaps  a  e  f  g  and  d  h  i  Jc  are  raised,  carried  downward,  and 
caused  to  fill  the  gap  a  b  c  d  hj  uniting  the  borders  h  i  and  e  f  with  each 
other  (Fig.  706). 

Elliptical  openings  of  large  size  can  be  closed  by  either  of  the  following 
plans  of  procedure  (Figs.  707  and  708).  In  the  former  the  flaps  a  c  d  e 
and  b  c  d  f  are  raised,  displaced  upward,  and  united  so  as  to  close  the  open- 


574 


OPERATIVE  SURaERY, 


ing.  In  the  latter  (Weber's  method)  the  flap  a  c  d  {?>  raised  and  carried 
upward  so  that  the  point  c  can  be  united  with  the  angle  &.  The  second  flap 
is  utilized  to  close  the  remaining  space  (Fig.  708). 


Fig.  707. — A  method  of  closing  elliptical 
opening. 


Fig. 


708. — Weber's  method  of  closing 
elliptical  opening. 


Jumping. — Jumping,  as  the  name  implies,  consists  in  "  jumping  a  flap 
connected  by  a  pedicle  over  intervening  undetached  tissues."     It  can  be 
done  with  or  without  the  pedicle  being  twisted  (Fig.  709). 
e 


Fig.  709. — Jumping,  pedicle  not  twisted. 

If  the  flap  be  not  moved  more  than  a  quarter  of  a  circle,  twisting  of  the 
pedicle  is  not  necessary.  Undercutting  is  employed  in  this  operation  when 
needed  to  adjust  the  parts  properly. 

In  Fig.  709  the  opening  a  6  c  is  closed  by  a  flap  jumped  a  quarter  of  a 
circle  and  united.    When  the  flap  is  moved  more  than  a  quarter  of  a  circle 

the  pedicle  will  be  twisted,  and  the  degree  of  twist- 
ing will  depend  on  the  distance  the  flap  is  moved. 
Fig.  710  illustrates  a  twisted  pedicle  improperly 
employed  in  the  repair  of  the  lower  lip. 

If  the  pedicle  be  too  much  twisted,  the  cir- 
culation of  the  flap  will  be  impeded,  and  slough- 
ing will  ensue. 

Inversion  and  Eversion. — These  methods  re- 
late to  the  employment  of  integument  in  the 
repair  of  mucous  membrane,  or  vice  versa. 
Tubular  formations  may  be  constructed  by 
either  of  these  methods,  as  in  the  formation 
of  new  canals,  like  the  urethra,  vagina,  and  the 
closure  of  an  extroverted  bladder. 

The  Tag-liacotian  Operation.— The  tagliacotian  operation  is  familiarly 
known  as  the  dissection  of  a  flap  from  another  and  distant  portion  of  the 


Fig.  710. — Jumping,  pedicle 
much  twisted. 


PLASTIC  SURGERY. 


575 


body,  and  after  graiiiilation  its  final  application  to  the  part  to  be  repaired, 
as  may  be  done  in  the  operation  for  the  construction  of  a  new  nose  (Fig. 
711). 

Grafting. — Grafting  by  the  entire  removal  of  a  thick  skin  flap  to  the 
locality  to  l)e  repaired  is  no  longer  practiced.  The  assured  success  of  the 
newer  methods  has  supplanted  almost  entirely 
all  attempts  witli  this,  the  older  one.  How- 
ever, severed  portions  of  the  nose,  ear,  and 
tips  of  the  fingers  are  sometimes  rescued, 
when  not  infected  or  badly  bruised,  by  im- 
mediate restoration  to  their  former  sites.  In 
such  instances  the  fragments  should  be  care- 
fully sewed  in  place  with  fine  sutures,  and 
dressed  so  as  to  keep  them  warm  and  with  a 
minimum  impairment  of  the  circulation.  A 
skin  flap  having  only  a  pedicle  of  subcutane- 
ous tissue  is  sufficiently  well  nourished  for 
plastic  repair  of  mucous  membrane  when 
turned  into  the  defect  without  twisting.  The 
mucous  membranes  of  the  urethra,  cheek,  etc., 
can  often  be  repaired  by  the  transplantation 
of  this  membrane  from  man  and  animals. 
The  loss  of  bone  tissue  is  occasionally  reme- 
died by  the  transplantation  of  large  pieces 
with  and  without  their  periosteum,  and  fre- 
quently by  small  ones  taken  from  near  the 

joints  of  the  young,  whose  bone  growth  is  active,  and  from  elsewhere,  and 
employed  successfully  with  (page  -150)  and  without  (page  335)  decalcifica- 
tion. Pieces  of  ivory,  sponge,  and  even  bone  ash  have  been  utilized  as  a 
framework  in  the  efforts  at  repair  by  the  development  of  new  bone.  As  the 
result  of  these  various  efforts,  curious  and  highly  important  ends  have  been 
accomplished  which  justify  the  efforts  and  emphasize  the  wisdom  of  a 
continuance,  and  the  belief  that  important  practical  benefits  may  arise  from 
the  labor. 

Shin-grafting  is  practiced  for  the  purpose  of  causing  the  healing  of  fresh 
and  granulating  surfaces  of  larger  or  smaller  size.  It  is  essential  to  success 
that  the  granulations  be  healthy  and  that  aseptic  care  be  exercised  in  the 
performance  of  the  grafting.  Three  methods  of  procedure  are  now  well 
recognized  :  one,  the  oldest,  Reverdin's  method,  the  others  and  the  more 
modern,  Thiersch's  and  Krause's  methods. 

Reverdin's  method  is  performed  by  first  making  small  punctures  in 
healthy  granulating  surface  with  the  sharp  end  of  a  common  pocket  probe, 
half  an  inch  or  so  apart ;  and,  second,  by  placing  over  the  open  mouths  of 
these  shallow  punctures  small  pieces  of  integument,  a  line  or  two  square, 
with  the  fresh  surface  downward.  They  are  then  pushed  into  the  openings 
of  the  punctures  by  the  same  probe,  in  such  a  manner  as  to  cause  a  close 
contact  between  the  raw  surfaces  of  the  small  "  grafts  "  and  those  of  the 


Pig. 


Italian  method. 


576 


OPERATIVE  SURGERY. 


punctures  in  the  granulating  surface.  Small  pieces  of  sterilized  lint  are 
placed  over  each  graft,  and  confined  in  position  by  narrow  strips  of  adhesive 
plaster.  The  part  should  be  carefully  redressed  at  the  end  of  three  or  four 
days.  At  this  time  small  flocculent  appearing  spots  will  be  noticed  corre- 
sponding to  the  seat  of  the  grafts,  if  it  have  been  successfully  placed.  The 
bits  of  skin  employed  are  taken  from  the  healthy  surface  of  the  donor  by 
means  of  a  fine  thumb  forceps  and  small  curved  scissors  and  include  the  rete 
Malpighii. 

Thiersch's  Method. — In  Thiersch's  method  the  raw  surfaces  of  strips  of 
the  epidermal  layer  of  the  integument  are  placed  in  contact  with  the  shaven 
or  curetted  base  of  an  ulcer,  and  with  fresh  surfaces  of  recent  wounds.  A 
sharp  razor,  saline  solution,  rubber  tissue  strips, aseptic  gauze,  aseptic  cotton, 
and  gauze  bandages  are  required  for  the  operation.  Neither  antiseptic  solu- 
tions nor  gauze  should  be  brought  in  contact  with  the  grafts,  as  the  contact 
will  impair  their  vitality.  The  tension  hooks  of  McBurney  (Fig.  693,  k)  are 
handy  and  serviceable,  although  not  essential,  as  the  skin  of  the  thigh  or 
arm — from  which  grafts  are  usually  taken — can  be  made  sufficiently  tense 
for  the  purpose  by  opposing  manual  traction  of  the  operator  and  the  as- 
sistant (Fig.  713).    Schleich's  No.  3  (page  39)  renders  removal  painless. 

The  Operation. — Make  tense  the  skin  at  the  outer  surface  of  the  thigh 
or  arm  (Fig.  712) ;  lay  the  razor  flatwise  on  the  surface  and  with  a  slow  to- 
and-fro  movement  split  the  integument  in  the  long  axis  of  traction,  making 
the  strips  of  such  length  and  width  as  is  necessary  or  convenient  (Fig.  713,  a). 


Fig.  712. — Cutting  grafts;  traction  hooks. 

The  graft  is  retained  on  the  upper  surface  of  the  blade  as  fast  as  formed, 
and  when  of  proper  length  is  divided  at  the  base  with  scissors  or  by  the  razor 
alone.  The  razor  with  the  graft  is  instantly  dipped  in  the  saline  solution 
and  the  graft  placed  in  position  by  a  reverse  motion  of  the  razor,  while  the 
base  of  the  graft  is  held  in  proper  place  with  the  finger  or  probe  (Fig.  713,  &) . 
The  presence  beneath  the  graft  of  air,  blood,  foreign  bodies,  etc.,  hinders 
union  and  may  prevent  it  altogether.  After  the  integumentary  grafts  are 
suitably  placed,  the  wound  is  covered  with  strips  of  aseptic  rubber  tissue  wet 


PLASTIC  SURGERY. 


577 


with  the  saline  sohition,  and  arranged  as  in  ordinary  strapping.  Aseptic  gauze 
and  sterilized  absorbent  cotton  follow,  held  in  place  with  a  gauze  bandage 
lightly  applied.  The  part  is  redressed  on  the  fourth  or  fifth  day.  The  occa- 
sional moistening  of  the  superimposed  dressings  with  the  saline  solution  is 
not  practiced  so  much  now  as  formerly,  and  there  is  good  reason  to  believe 
that  undue  importance  has  been  attached  to  this  practice  in  the  past. 

Krause's  Method. — The  preparations  for  grafting  require  that  the  in- 
tegument to  be  used  for  the  purpose  shall  be  bathed  with  a  bichloride 


-  rij^,^ 


Fig.  713. — a.  Cutting  grafts  without  traction  hooks,     h.  Placing  graft  in  position. 

solution,  rinsed  with  the  saline,  and  wiped  dry  with  and  surrounded  by  steril- 
ized gauze.  The  seat  of  repair  should  be  fresh,  all  granulation  tissue  being 
removed  down  to  the  normal  structures  with  a  knife,  and  the  surface 
thoroughly  cleansed  with  the  aforementioned  solutions,  the  bleeding  arrested, 
and  surface  pressed  dry  with  sterilized  gauze.  The  grafts  should  be  oval  or 
spindle-shaped,  include  the  skin  only,  and  be  outlined  before  raising ;  they 
should  be  promptly  and  aseptically  dissected  up  with  forceps  and  scalpel, 
placed  in  position  without  moistening,  and  gently  pressed  into  close  contact 
with  the  surface,  and  carefully  confined  there  with  sterilized  or  iodoformized 
gauze  supplemented  by  additional  gauze  closely  confined  in  place  with 
bandages. 

The  Remarlcs. — The  part  to  be  repaired  should  be  made  anaemic  when 
possible  by  elastic  pressure,  and  the  grafts  applied  and  the  part  dressed 
before  the  elastic  bandage  is  removed,  thus  hastening  the  procedure  and 
facilitating  union.  For  it  is  stated  (Fischer)  that  grafts  removed  from  and 
applied  to  parts  made  anaemic  by  such  pressure  unite  more  promptly  than 
when  otherwise  treated.  The  subcutaneous  fat  should  be  entirely  removed 
from  the  flap.  These  flaps  thrive  when  applied  to  muscle,  fascia,  bone,  etc., 
and  with  nearly  equal  vigor.  The  fact  that  they  appear  discolored  and 
swollen  in  a  few  days  need  not  excite  apprehension,  as  they  frequently  thus 
appear  in  successful  cases.  The  dressings  directly  in  contact  with  the  wound 
should  not  be  removed  until  they  are  thoroughly  loosened  by  saturation  with 
warm  saline  or  boric-acid  solutions,  to  prevent  disturbing  the  grafts. 

Lusk''s  {Z.  J.)  Method. — In  cases  in  which  for  any  reason  the  preceding 
methods  are  objectionable,  this  method  can  be  employed  with  satisfactory 
results.  Its  application  is  attended  with  comparatively  little  annoyance, 
and  consists  in  utilizing  for  the  purpose  the  epithelium  covering  blistered 
surfaces.     This  epithelium  is  cut  away  while  attached  to  overlying  sterilized 


578 


OPERATIVE   SURGERY. 


gauze,  treated  for  a  few  minutes  with  a  warm  solution  of  boric  acid,  divided 
into  pieces  a  line  or  so  square,  each  of  which  is  carefully  pressed  at  a  suit- 
able distance  from  its  fellow  upon  the  granulating  surface  already  treated 
with  weak  sublimated  and  saline  solutions  respectively.  Lusk  advises  that  a 
layer  of  sterilized  gauze  saturated  with  a  solution  of  balsam  of  Peru  (one 
drachm)  and  castor  oil  (one  ounce)  be  applied  to  the  grafted  surface.  Two 
or  three  layers  of  sterilized  cotton  in  addition,  held  in  place  with  a  roller 
bandage,  complete  the  dressing.  After  three  or  four  days  the  superficial 
dressing  should  be  changed,  but  the  deep  dressing,  whether  of  gauze  or 
rubber  tissue,  may  remain  undisturbed  for  ten  or  twelve  days. 

The  Remarks. — If  sterilized  gauze  or  rubber  tissue  be  placed  upon  the 
cuticle  and  attached  to  it  before  the  cutting,  the  cuticle  can  be  readily 
handled,  raised  up,  or  cut  into  pieces  along  with  the  supporting  structure, 
and  applied  and  held  in  place  by  the  overlying  strip. 

Croffs  Operation  for  Cicatricial  Contraction. — Croft's  method  consists 
in  jumping  a  prepared  flap  into  a  gap  resulting  from  a  free  incision  of  a 
band  of  cicatricial  tissue  of  greater  or  lesser  width.  The  operation  can  be 
practiced  in  any  part  of  the  body  where  a  proper  area  of  unaffected  tissue 
can  be  utilized  for  the  purpose.  The  rationale  of  the  procedure  is  illustrated 
best  in  connection  with  cicatricial  contraction  at  the  arm  (Fig.  714).  Make 
the  integumentary  bridge  as  long  as  practicable,  in  healthy  tissue,  and  as 
thick  as  possible,  especially  at  the  center;  approximate  the  sides  of  the 
wound  with  sutures,  carefully  avoiding  interference  with  the  bases  of  the 
\      fc^^^  J       1  flap ;  separate  the  bridge  of 

•      *"^^     /  skin   from   the    tissues  be- 

hfis  / '  neath  by  a  layer  of  oiled  silk 

"®i   """  ^"  _  dipped  in  carbolized  oil,  be- 

ing careful  to  make  the 
separation  complete  at  the 
bases,  to  avoid  shortening  of 
the  flap  by  granulation  of 
contiguous  borders ;  cover 
the  entire  area  lightly  with 
antiseptic  dressing  and  fix 
the  part  in  an  immovable 
position.  At  the  end  of  two 
or  three  weeks  cut  through 
the  cicatricial  tissue  down  to 
healthful  fascia  and  muscle  ; 
arrest  haemorrhage  ;  divide 
the  integumentary  bridge ; 
freshen  the  borders  of  the 
flap  and  lodge  the  extremity  in  the  cicatricial  gap,  being  careful  that  they 
conform  with  each  other  as  nearly  as  possible  in  shape  and  extent,  and  also 
that  the  free  end  of  the  flap  be  properly  united  to  the  opposite  border  of 
the  gap.  The  parts  are  held  in  place  by  careful  dressing,  and  the  flap — 
especially  the  distal  end — is  cautiously  treated  to  avoid  sloughing.     Much 


"^ 


Fig.  714. — Croft's  operation. 


PLASTIC   SURGERY. 


570 


time  is  required  to  secure  the  degree  of  union  that  bespeaks  a  successful 
issue  of  the  attempt;  six  or  eight  months  are  often  necessary  for  cure. 


Fig.  715.— Flap  with  single 
pedicle. 


Fig.  716.— Flaps  with  double  pedicle. 


Examples  of  repair  of  a  similar  nature,  in  which  pedunculated  flaps  are 
raised  from  another  than  the  afflicted  portion,  and  placed  in  contact  with 
the  granulated  or  freshened  surfaces  of  it,  are  practiced  (Figs.  715  and  716). 


Fig.  717. — Single  pedicle,  forearm. 


Fig.  718. — Single  pedicle,  author's  case. 


580  OPERATIVE  SURGERY. 

These  flaps  include  the  subcutaneous  tissues,  and  their  dimensions  are  esti- 
mated on  the  lines  of  recognized  tissue  contraction,  as  stated  (page  569). 
The  borders  of  the  flaps  are  united  with  sutures  to  one  or  both  of  those  of 
the  defect,  and  thus  maintained  until  proper  union  is  assured.  Ordinarily, 
in  the  instance  of  a  double  pedicle  (Fig.  716),  one  pedicle  may  be  divided 
after  ten  or  twelve  days,  the  other  a  week  or  so  later.  If  only  a  single 
pedicle  be  present  (Figs.  717  and  718),  the  division  is  delayed  two  weeks  or 
more,  according  to  its  size,  the  condition  of  the  circulation  of  the  flap,  and 
the  state  of  the  patient.  It  is  wise  to  remember  that  a  few  days  of  delay  is 
better  than  to  precipitate  action  in  the  division  by  even  one  day. 

The  Remarks. — In  these  instances  the  raw  surfaces  due  to  raising  the 
flap  should  be  closed  at  once,  if  practicable,  by  sutures,  or  covered  then  or 
later  by  skin  grafting.  The  interposition  of  rubber  tissue  or  oiled  silk  at 
the  bases  of  the  pedicles,  to  prevent  their  shortening  by  healing,  and  also 
between  the  limb  and  body  to  obviate  union  of  any  apposed  raw  surfaces,  is 
advisable.  Thorough  antiseptic  practice  should  characterize  throughout  the 
operative  and  post-operative  treatment. 

Rhinoplasty. — Ehinoplasty  consists  in  the  reproduction  of  a  part  or  the 
whole  of  the  nasal  organ.  The  present  ability  of  the  surgeon  to  arrest  the 
diseases  causing  deformities  of  the  nose  has  lessened  the  frequency  of  this 
operation.  Ingenious  contrivances  of  ivory,  rubber,  etc.,  have  been  made  to 
fit  the  deformity,  and  to  thus  supply  a  substitute  for  the  lost  parts.  These 
Contrivances,  when  tinted  to  conform  to  the  complexion  of  the  wearer,  often 
prove  quite  deceptive  to  the  observer ;  but,  being  unaffected  by  the  various 
contingencies  of  the  weather  and  the  emotions,  they  are  apt  at  times  to  cause 
the  wearer  to  present  a  ludicrous  appearance. 

In  operating  on  the  nose  for  deformity,  save  all  that  is  possible  of  its 
cartilaginous  and  bony  tissues,  for  they  will  each  afford  important  supports 
for  the  new  structure.  The  cartilages  of  the  alae  should,  when  possible, 
constitute  the  free  border  of  the  new  structure. 

The  deformities  of  this  organ  may  be  due  :  1,  to  a  loss  of  the  superficial 
soft  parts,  which  may  vary  in  extent  and  degree ;  2,  to  a  loss  of  the  bony 
or  cartilaginous  septum,  with  or  without  loss  of  the  nasal  bones ;  or,  3,  to  a 
loss  of  both  combined.  The  soft  parts  may  be  restored  by  utilization  of  one 
of  the  methods  before  named.  The  extent  of  the  deformity  and  its  situation 
will  determine  the  choice  of  a  method.  When  the  loss  of  the  integument 
is  small  and  does  not  involve  the  alse  and  the  deeper  structures,  the  de- 
fect may  be  remedied  by  the  direct  approximation  of  its  borders,  aided, 
of  course,  by  a  free  undercutting  with  or  without  parallel  incisions.  The 
French  method,  by  transverse  incisions  combined  with  undercutting,  can  be 
employed  (Fig.  719)  when  the  former  is  deemed  inadequate. 

The  author  some  time  ago  fashioned  a  quadrilateral-shaped  flap  from 
either  cheek  with  the  pedicles  downward  and  supplied  with  blood  from  the 
vessels  of  the  upper  lip,  carried  them  inward,  with  the  raw  surfaces  un- 
derneath, and  united  them  with  each  other  at  the  median  line  of  the  nose, 
and  to  the  freshened  border  at  the  bridge,  for  the  purpose  of  closing  a  large 
defect  resulting  from  the  removal  of  all  of  the  soft  parts  of  the  nose,  except 


PLASTIC   SURGERY. 


581 


the  septum  and  columna,  and  of  the  interorbital  space,  on  account  of  a  luxu- 
riant epithelial  cancer.  The  flaps  united  promptly  and  afforded  a  sym- 
metrical and  complete  covering  of  the  gap.  However,  the  retractile  forces 
of  the  tissue  of  the  checks  soon  caused  undue  flattening  of  the  nose,  which 
deformity  remained  undisturbed,  as  the  patient  expressed  a  high  degree 
of  satisfaction  with  the  result,  not 
fully  shared  by  the  author.  As  evi- 
denced by  the  presence  of  cicatricial 
tissue  at  the  root  of  the  nose,  and 
emphasized  by  the  knowledge  of  the 
obliteration  of  the  angular  arteries  by 
the  previous  operation,  this  procedure 
appears  here  to  have  afi^orded  the  best 
solution  of  the  problem.  The  gaps 
in  the  cheeks  were  closed  with  sutures 
and  quickly  healed.  The  nostrils  were 
supported  with  pieces  of  drainage  tube 
(Fig.  721)  covered  with  iodoform  gauze, 
and  the  whole  lightly  covered  with 
aseptic  dressing.  The  extended  ap- 
plication of  this  method  is  particu- 
larly useful  in  those  cases  in  which  Fig.  719.— Closure  by  transverse  incision, 
the  upper  part  of  the  nose  is  intact. 

However,  the  tissue  of  the  cheek  is  not  so  well  adapted  to  nasal  repair 
as  is  that  of  the  forehead,  owing  to  a  lesser  degree  of  direct  vascularity 
and  greater  contractile  tendencies.  In  still  another  instance  two  quadri- 
lateral-shaped flaps — one  from  either  cheek — were  turned  over  and  united  at 
the  median  line  of  the  nose  and  the  raw  upper  surface  was  grafted  by 
Thiersch's  method.  For  some  time  the  appearance  of  the  organ  was  entirely 
satisfactory ;  later,  however,  contraction  caused  it  to  assume  a  saddle  shape. 
It  was  then  proposed  to  rectify  the  deformity  with  another  flap,  but  the 
patient  did  not  return  to  the  hospital. 


Fig.  720.  —  Syme's  operation,  bilobar 


Fig.  721. — Syme's  operation,  flaps  in 
place. 


Syme's  Operation. — Syme's  operation  is  a  fair  illustration  of  the  extended 
method  of  procedure.  A  symmetrical  bilobar  flap  (Fig.  730)  is  formed  from 
the  cheeks,  the  pedicle  {a)  being  located  at  the  root  of  the  nose;  the  area  and 


582 


OPERATIVE  SURGERY. 


Fig,  733,— Repair 
by  jumping. 


borders  of  the  gap  are  freshened;  the  flap  is  placed  in  position,  and  the 
lobar  portions  are  united  with  each  other  in  the  median  line  and  with  the 
freshened  borders  of  the  gap  at  the  sides  (Fig.  721).  The 
nostrils  are  supported  by  rubber  tubes,  the  gaps  on  the 
face  closed  with  sutures,  and  the  entire  wound  is  covered 
lightly  with  aseptic  dressing. 

The  Remarhs. — The  cicatrization  of  the  triangular- 
shaped  places  at  the  sides  of  the  nose  apparently  increases 
the  height  of  the  organ.  If  a  septum  be  present  the  trans- 
fixion of  the  entire  structure  at  the  outer  and  lower 
borders  of  the  flaps  with  a  fine  needle  will  provide  satisfac- 
tory support  during  the  healing  process. 

If  the  extremity  of  the  nose  or  the  alse  be  involved, 
sliding  in  a  curved  line,  the  flap  having  either  curved  or 
angular  borders,  is  recommended.  Figs.  732  and  723  repre- 
sent the  restoration  of  the  alse  by  a  flap 
taken  from  the  cheek  and  upper  lip.  The 
flap  must  be  of  sufficient  size  to  allow  at 
least  one  fourth  for  its  contraction,  other- 
wise when  united  in  position  it  will  dis- 
place the  axis  of  the  nose,  thereby  substi- 
tuting one  deformity  for  another.  Langen- 
hech  repaired  a  similar  deformity  by  taking 
a  flap  from  the  opposite  side  of  the  nose 
(Fig.  724).  As  in  the  preceding  method, 
the  dissection  must  be  carefully  made  down 
to  the  cartilaginous  framework.  The  border 
of  the  new  ala,  although  freshly  cut,  heals 
in  a  satisfactory  manner.  Fig.  725  shows 
the  line  of  incision  employed  to  repair  the 
deformity  with  a  flap  possessing  an  already 
cicatrized  border.  The  vascular  supply  of 
this  flap  is  not  active,  and  every  precau- 
tion should,  therefore,  be  taken  to  provide  against  the  danger  of  sloughing. 
The  incision  is  begun  at  the  sound  side,  near  the  tip  of  the  nose,  and  ex- 


FiG.  733.— Ellis's  method,  from  lip 
and  cheek. 


Fig.  784. — Langenbeck's  method. 


Fig,  735. — Denonvillier's  method. 


PLASTIC  SURGERY. 


583 


tended  upward  close  to  the  root  of  the  nose,  thence  obliquely  downward  and 
outward,  terminating  at  the  upper  and  outer  angle  of  the  defect.  The  lower 
part  of  the  flap  should  contain  a  portion  of  cartilage,  for  obvious  reasons. 


Fig.  726.— Buck's  method. 


Fig.  727.— Buck's  method. 


After  the  edges  of  the  defect  are  freshened,  the  flap  is  slid  carefully  into 
the  gap  and  united  there  with  horsehair  sutures. 

Weher  cured  a  defective  ala  with  a  flap  taken  from  the  upper  lip,  the 
pedicle  being  continuous  with  the  columna.  The  flap  was  oval,  included  a 
portion  of  the  thickness  of  the  lip  only,  and  was  slid  into  the  gap  and 
united  with  its  freshened  borders  by  horsehair  sutures.  At  the  end  of  four 
weeks  the  pedicle  was  divided  and  turned  upward  to  improve  the  sym- 
metry of  the  nose.  If  either  ala  be  absent,  and  the  resulting  gap  be  large, 
the  material  for  its  repair  can  be  taken  from  the  forehead,  as  will  be  under- 
stood by  consulting  Figs.  726  and  727.  It  will  be  seen  that  the  pedicles  are 
admirably  located  to  receive  ample  nourishment.  The  loss  of  the  end  of 
the  nose  may  be  repaired  also  from  the  tissue  of  the 
upper  lip  or  the  cheek. 

If  the  columna  be  absent,  it  may  be  replaced  by 
structures  taken  from  the  upper  lip  (Fig.  728). 
In  this  operation  it  is  better  to  include  the  whole 
thickness  of  the  lip  (b  c,  h'  c'),  tipping  the  flap  di- 
rectly upward  into  place,  than  to  make  an  integu- 
mentary flap  the  adjustment  of  which  will  require  a 
sharp  twisting  of  the  pedicle.  In  the  former  in- 
stance the  cuticle  is  dissected  off  and  the  raw  sur- 
face carried  directly  into  its  position.  The  mucous 
surface  of  the  flap  soon  assumes  integumentary 
characteristics.  If  the  lip  be  deficient,  a  flap  can  be 
taken  instead  from  beneath  either  ala  or  from  the  dorsum  of  the  nose  (a) 
(Heuter)  and  carried  into  place. 


Fig.  728.— Repair  of 
cohimna. 


584 


OPERATIVE  SURGERY. 


Loss  of  the  Bony  or  Cartilaginous  Septum,  with  or  without  Loss  of 
the  Nasal  Bones. — The  loss  of  the  cartilaginous  portion  of  the  septum,  the 
other  tissues  remaining  intact,  causes  a  flattening  at  the  end  of  the  nose  or 
a  depression  at  the  lower  end  of  the  nasal  bones.  The  operation  of  sliding 
the  tissues  may  temporarily  relieve  the  deformity,  but  subsequent  retraction 
of  the  tissues  is  apt  soon  to  reproduce  it. 

If  the  nasal  bones  be  intact,  the  loss  of  the  bony  septum  is  not  mani- 
fested by  any  external  deviation  of  the  organ.  If  the  septum  and  nasal 
bones  be  gone,  it  then  becomes  necessary,  in  order  to  relieve  the  deformity, 
to  elevate  and  maintain  in  position  the  tissues  composing  the  soft  parts 
of  the  nose.  To  accomplish  this  purpose  it  requires  an  internal  support  of 
some  sort,  although  much  may  be  gained  by  dissecting  up  the  soft  parts 
at  each  side  of  the  nose  and  raising  them  in  the  line  of  the  bridge,  by 
approximating  their  bases  by  means  of  pins  passed  through,  and  then  con- 
fining them  in  position  until  union  of  the  flaps  takes  place. 

Dieffenhach's  Method.— In  1829 
Dieffenbach  published  a  method  of 
operation  by  which  he  overcame  the 
deformity  resulting  from  the  loss  of 
the  nasal  bones  and  the  septum 
(Fig  729).  An  incision  was  made 
with  a  narrow-bladed  knife  along  the 
outer  side  of  the  sunken  border  of 
each  nostril  (a),  the  intervening 
strip  (c)  being  three  times  broader 
at  its  connection  with  the  upper  lip 
than  where  it  joined  the  forehead 
above.  At  the  outer  side  of  each  of 
these  incisions  another  ((/)  was  made 
down  to  the  bone,  which  began  a  few 
lines  below,  and  to  the  outer  side  of 
the  upper  extremit}^  of  the  first,  and 
was  carried  obliquely  downward, 
parallel  with  the  primary  one  and  external  to  the  side  of  the  nose,  around 
into  the  nostril,  thereby  separating  the  ala.  The  columna  was  elongated  by 
short,  parallel  incisions  in  the  upper  lip,  and  the  cheeks  were  dissected  up 
from  their  bony  attachments,  through  the  lateral  cuts,  sufficiently  to  render 
them  freely  movable.  The  flaps  (c  d  d')  were  then  raised,  and  their  lower 
borders  having  been  pared  obliquely,  were  reunited,  fastened  with  pins  and 
sutures,  and  retained  in  position  by  drawing  the  detached  portions  of  the 
cheeks  toward  the  median  line  of  the  nose,  in  which  position  they  were  fixed 
by  two  long  pins  passed  through  their  borders  (e  e')  under  the  nose.  The 
pins  were  passed  through  two  narrow  strips  of  leather,  which  equalized 
the  force  and  prevented  the  production,  by  the  pins,  of  premature  ulcera- 
tion. A  quill  surrounded  by  oiled  lint  was  then  introduced  into  each 
nostril  with  the  idea  of  holding  the  nostrils  open  without  irritation  during 
healing. 


Fig.  729. — Dieffenbach's  method. 


PLASTIC  SURGERY. 


585 


Superimposed  superficial  flaps  were  successfully  employed  by  Verneuil. 
In  this  case  the  alas  and  tip  of  the  nose  were  uninjured,  but  were  tipped 
upward  and  the  bridge  of  the  nose  was  flattened. 

The  Operation. — Make  an  incision  in  the  median  line  of  the  nose,  down 
upon  the  hard  structures  from  the  root  of  the  organ  to  a  little  below  the 
upper  border  of  the  cartilage  (Fig.  730,  a).  Make  a  transverse  incision 
across  the  upper  and  lower  ends  of  the  vertical  one  (the  upper  ones  being 
downward  and  outward)  down  to  the  bone ;  raise  two  lateral  flaps  composed 
of  the  soft  parts  and  periosteum  if  possible,  also  any  fragment  of  a  nasal 
bone  that  is  present  (Fig.  T30,  h)  :  separate  the  cartilaginous  portions  of 


a  c  d 

Fig.  730. — Verneuil's  method  of  operation. 
a.  The  lines  of  incision  for  the  flaps,     b.  The  flaps  reflected,  tip  of  nose  freed  and  in  po- 
sition,    c.  The  flap  from  forehead  sutured  in  place,     d.  The  lateral  flaps  united  over 
forehead  flap ;  gap  at  root  of  nose  closed  by  sutures,  later  by  stump  of  forehead  flap. 

the  nose  from  the  bony  by  a  transverse  incision  opening  into  the  nasal  cavity, 
thence  sufficiently  through  the  cartilaginous  septum  to  permit  of  the  tip  of 
the  nose  being  properly  adjusted.  Eaise  a  vertical  flap  from  the  fore- 
head, of  suitable  length  and  about  a  quarter  of  an  inch  in  width,  composed 
of  the  soft  parts  and  external  table  of  bone,  in  the  following  manner :  j\Iake 
a  vertical  incision  at  either  side  of  the  median  line  of  the  forehead,  about 
a  quarter  of  an  inch  apart  from  a  point  half  an  inch  above  the  root  of  the 
nose,  upward  to  a  distance  ample  to  furnish  a  suitable  bridge,  with  the 
tip  of  the  organ  properly  adjusted  (Fig.  730,  c).  Shave  off  the  cuticle  of 
the  lower  end  of  the  flap,  so  as  to  correspond  with  the  freshened  surface  on 
the  dorsum  of  the  nose,  leaving  untouched  the  cuticle  corresponding  to 
the  opening  into  the  nasal  cavity.  Cut  through  the  external  table  corre- 
sponding to  the  vertical  incisions  with  a  thin  sharp  chisel,  then  introduce  a 
chisel  of  about  the  width  of  the  flap  through  the  transverse  incision  at  the 
upper  end  and  direct  the  instrument  downward,  so  as  to  remove  with  the 
skin  flap  the  external  table  of  the  frontal  bone;  break  off  the  flap  at  the 
39 


586 


OPERATIVE   SURGERY. 


lower  end,  turn  it  downward;  push  the  tip  of  the  nose  into  place  and 
adjust  the  flap  to  the  nose  and  tip  so  as  to  hold  the  latter  in  proper  posi- 
tion ;  stitch  the  extremity  of  the  reflexed  flap  to  the  freshened  cartilaginous 
border  (Fig.  730,  c),  adjusting  its  cutaneous  surface  so  as  to  conform  with 
the  opening  into  the  nose;  liberate  the  lateral  flaps  freely  in  order  to  per- 
mit of  their  being  raised  and  united  in  the  median  line  over  the  reflected 
flap ;  close  the  wound  of  the  forehead  with  sutures,  leaving  the  pedicle  of  the 
flap  free  from  constriction  for  obvious  reasons;  divide  the  pedicle  of  the 
reflected  flap  after  three  weeks,  and  turn  upward,  and  fit  the  remnant  into 
the  gap  of  the  frontal  wound  (Fig.  730,  d). 

The  Remarks. — The  vertical  flap  ought  not  to  contain  hair  follicles. 
The  long  portion  of  the  reflected  flap  may  become  absorbed,  followed  by 
marked  depression  of  the  bridge.  At  the  time  of  operation  a  piece  of  suit- 
ably shaped  celluloid  of  sufficient  length  to  hold  the  end  of  the  nose  prop- 
erly adjusted  may  be  covered  in  by  the  reflected  flap.  It  is  better,  however, 
to  introduce  the  supplementary  agents — i.  e.,  celluloid,  paraffin,  chicken 
bone,  etc. — after  sound  healing  has  taken  place,  as  then  a  better  estimate 
can  be  made  of  the  degree  of  deformity  to  be  corrected,  and  the  difficulties 
arising  from  infection  are  reduced  to  a  minimum. 

In  this  connection  we  are  prompted  to  impress  on  the  attention  of  the 
operator  the  great  need  of  securing  and  preserving  a  substantial  flap. 
Care  in  handling  and  in  subsequent  protection  from  extremes  of  all  kinds 
are  highly  requisite.  At  the  best,  more  or  less  disappointment  on  the  part 
of  the  patient  is  probable,  and  it  ought  always  to  be  tempered  by  a  discreet 
prognosis. 

The  Indian  Method  (Fig.  731).— The  Indian  method  was  at  one  time  the 
prevailing  method  of  operation  when  the  septum  and  a  large  portion  of  the 

soft  parts  of  the  nose  were  absent,  and 
was  employed  even  when  the  lower  ex- 
tremities of  the  nasal  bones  had  sustained 
a  loss.  The  tendency  to  atrophy  and  slid- 
ing down  of  the  flap  after  union  had  taken 
place,  accompanied  by  closure  of  the  nos- 
trils and  danger  to  the  life  of  the  patient 
from  the  operation,  bid  fair  for  a  time  to 
cause  the  substitution  for  it  of  more  satis- 
factory measures.  However,  modern  mod- 
ifications have  placed  it  again  in  the  list 
of  wise  operative  procedures.  Before  active 
measures  are  begun,  a  false  nose,  conform- 
ing to  the  cosmetic  requirements  of  the 
face,  should  be  fashioned  from  gutta- 
percha, plaster,  or  other  suitable  material, 
and  placed  in  position.  Then  the  superficies  of  the  artificial  appliance 
should  be  carefully  estimated  by  measurement,  and  a  pattern  corresponding 
to  the  same,  including  the  alse,  columna,  etc.,  should  be  formed  of  some 
flexible  though  inelastic  substance.     This  pattern  is  an  exact  measure  of 


Fig.  731. — The  Indian  method. 


PLASTIC  SURGERY. 


587 


the  prepared  lljip  plus  nii  increase  in  size  oF  one  thiiil  in  all  directions,  to 
provide  for  subsequent  shrinkage. 

The  Operation. — Freshen  the  l)orders  ol'  the  defect  thoroughly  and 
evenly ;  reflect  downward  a  small  quadrilateral-shaped  flap  from  the  skin  at 
the  root  of  the  nose  (a)  when  possible,  leaving  the  base  attached  and  the 
raw  surface  uppermost.  This  flap  adds  to  the  compactness  of  the  nose 
and  serves  also  to  anchor  the  main  flap  more  flrmly  in  position,  thus 
preventing  the  downward  sliding  that  formerly  characterized  this  plan  of 
procedure.  Place  the  pattern  of  the  large  flap  obliquely  on  the  forehead 
and  mark  its  outline  with  the  pedicle  located  at  one  side  of  the  root  of 
the  nose  (c).  The  pedicle  (&)  should  be  about  half  an  inch  in  width  and 
include  the  supratrochlear  artery  of  the  side  on  which  it  is  situated.  The 
integument  corresponding  to  the  side  opposite  to  the  proposed  pedicle 
should  be  divided  in  a  curved  direction  down  to  the  freshened  gap,  thus 
laying  off  one  side  of  the  pedicle,  which  is  permitted  thereby  to  be  more 
readily  and  safely  turned  when  the  flap  is  placed  in  proper  position.  The 
flap  is  now  made  by  dividing  the  tissues  freely  down  to  the  periosteum,  in 
the  course  of  the  indicating  line,  the  bleeding  being  controlled  by  sponge  and 
digital  pressure.  Serre-fine  clamps  (Fig.  103)  are  admirable  for  the  arrest 
of  hemorrhage  at  the  borders  of  the  wound  at  this  time.  The  flap  is  raised 
— leaving  the  periosteum  behind — turned,  and  placed  in  the  required  posi- 
tioU;,  and  the  borders  carefully  united  with  those  of  the  freshened  gap  with 
sparsely  placed  and  carefully  tied  sutures  of  horsehair  or  silkworm  gut.  The 
alse  and  columna  are  then  secured  in  a  similar  manner.  The  columna  may  be 
formed  either  by  inserting  the  elongation  connected  with  the  flap  into  a  slit 
made  at  the  upper  border  of  the  median  portion  of  the  lijD,  or,  if  this  be  not 
present,  by  turning  iipward  a  narrow  strip  from  the  upper  lip  and  fastening 
it  in  position.     The  nostrils  are  supported  and  the  formation  of  the  nasal 


Fig.  732. — Thiersch's  rhinoplasty. 


m' 

a  b 

Fig.  733. — Formation  of  a  bony  framework 
for  the  nose.     (Langenbeck  and  Oilier.) 


openings  assured  by  the  introduction  of  pieces  of  suitable  sized  drainage 
tubes  (Fig.  721)  or  quills  covered  with  iodoform  gauze,  for  a  considerable 
length  of  time.  The  wound  of  the  forehead  is  closed  as  best  it  may  be  by 
harelip  pins  or  sutures  properly  placed.     The  unclosed  part  can  be  treated 


588 


OPERATIVE  SURGERY. 


at  once  by  skin  grafting,  or  be  allowed  to  heal  by  granulation.  A  light 
antiseptic  covering  held  loosely  in  place  completes  the  primary  dressing. 

The  after-treatment  is  controlled  entirely  by  subsequent  requirements 
of  the  cases.  Whatever  operative  steps  are  essential  to  secure  usefulness 
and  symmetry  of  the  organ  are  employed  as  the  indications  arise. 

Various  mechanical  expedients  are  employed  to  prevent  depression  and 
flattening  of  the  amended  organ,  such  as  gold  and  platinum  bridges,  levers, 


d 


Fig.  734. — The  triangular  flap,  c  a', 
a  c' .  Short  vertical  incisions,  a  b', 
b  a'.  Lines  of  bending,  d  d' .  Median 
line.     d.  Columna. 


Fig.  735.  —  DiefEenbach's  flap,  d  d'. 
Median  line,  c'  a  ,  d  a.  Short  verti- 
cal incisions,  b  a'  c,  V  a  c.  Lines 
of  bending. 


etc.  However,  it  is  quite  rare  that  they  afford  a  degree  of  satisfaction  that 
is  at  all  commensurate  with  the  annoyance  which  they  cause.  Vitalized  sup- 
port is  often  obtained  through  the  agency  of  two  small  longitudinal  skin 
flaps  {a  I)  turned  inward  from  the  borders  of  the  gap  and  placed  with  the 
raw  surfaces  outward,  thus  affording  support  to  the  main  flap  (c)  (Fig. 

732)  (Thiersch).  Pieces  of  bone  taken 
from  each  side  of  the  osseous  aperture 
with  a  fine  saw  and  raised  upward  so  as  to 
form  a  supporting  arch  for  the  soft  parts 
was  advised  by  Langenheck  (Fig.  733,  1, 
2,  a  and  h ) .  The  pedicle  is  divided  usually 
at  the  end  of  the  fourth  week,  and  the 
attached  portion  is  utilized  to  lessen  dis- 
figurement, if  practicable. 

The  outlines  in  the  main  flap  differ 
somewhat,  four  important  varieties  being 
recognized : 

1.  The  triangular  form  (Fig.  734).  In 
this  variety  quadrilateral  flaps  are  formed 
at  eithet  side  of  the  base  by  short,  vertical  incisions  {c'  a,  c  a').  The  mid- 
dle part  is  utilized  for  the  columna  {d),  and  the  lateral  parts,  when  prop- 
erly fashioned,  and  bent  on  lines  &  a',  ah',  form  the  alse. 


Fig.  736. — Langenbeck's  flap,  d  d'. 
Median  line,  a'  c,  c'  a.  Columna. 
b  a',  a  b'.  Lines  of  bending. 


PLASTIC   SURGERY. 


589 


2.  The  pyriform  flap  of  Dieft'enbach  (Fig.  735)  differs  only  in  shape 
from  the  preceding.  The  vertical  incisions  (c'  a,  c'  a')  are  cut  as  before,  and 
the  resulting  flaps  are  utilized  by  bending  for  similar  purposes. 

3.  Langenbeck's  flap  (Fig.  736)  is  shaped  something  like  the  ace  of 
spades.  The  central  segment  (c  a',  c'  a)  forms  the  columna  and  the  lateral 
ones  (a  h'  and  b  a')  the  ahv. 

4.  Keegan's  Operation. — Surgeon-major  Keegan  has  devised  and  carried 
into  effect  on  repeated  occasions  and  with  eminent  success,  an  ingenious 
reparative  measure  for  nasal  deformity  deeply  involving  the  end  of  the  nose. 

The  Operation. — From  points  slightly  external  to  the  alae  nasi  carry 
upward  two  converging  incisions  to  points  at  either  side  of  the  bridge  of 
the  nose  about  three  quarters  of  an  inch  apart,  corresponding  to  the  place  at 
which  spectacles  are  commonly  adjusted  {a  c,  f  h)  (Fig.  737,  &).  Connect 
these  points  by  a  transverse  incision  (a  f) ;  bisect  the  transverse  one  with  a 
perpendicular  incision  (h  d)  carried  downward  along  the  bridge  of  the  nose 
to  nearly  the  free  borders  of  the  nasal  bones;  dissect  these  flaps  (abed, 
efg  h)  downward  almost  to  the  free  margin  of  the  bones,  which  part  is  left 


Fig.  737. — Keegan's  operation. 

undisturbed.  An  obliquely  placed  flap  of  proper  size  and  corresponding  to 
the  one  depicted  in  the  cut  (Fig.  737,  a),  with  the  pedicle  at  the  inner  angle 
of  the  eye,  is  now  raised  from  the  forehead.  The  nasal  flaps  already  de- 
scribed are  turned  downward  at  the  bases  (r  d  and  g  h)  and  properly  fitted 
by  the  cutting  ofE  of  the  overlapping  portions,  thus  leaving  their  raw  sur- 
faces uppermost.  The  main  flap  (a)  is  now  turned  downward  and  placed  in 
position.  The  free  margins  of  the  frontal  and  nasal  flaps  are  united  with 
horsehair  sutures,  the  columnar  segment  is  properly  joined  below,  and  the 
lateral  nasal  incisions  are  suitably  fitted  to  accurately  meet  the  main  flap, 
to, which  they  are  joined  carefully  with  horsehair  sutures.  The  wound  of 
the  forehead,  the  newly  formed  nostrils,  and  the  final  dressings  are  man- 
aged in  all  substantial  respects  as  in  the  preceding  instance.  The  pedicle  is 
divided  at  the  end  of  two  weeks.  The  tendency  of  the  flap  to  slide  down- 
ward has  been  combated  in  various  ways — such  as  connecting  the  pedicle 


590  OPERATIVE   SURGERY. 

with  a  longitudinal  incision  at  the  side  of  the  nose,  the  attachment  of  its 

whole  length  to  a  newly  formed  raw  surface  at  its  base,  and  grafting  the 

sharpened  pedicle  into  the  integument  at  its  base. 

In  these  operations,   after  the  columna   and   alse  are  fashioned  and 

sutured  in  place,  the  end  of  the  nose  presents  from  below  a  quite  natural 

appearance  (Fig.  738). 

The  Italian  Method. — The  Italian  method,  although  an  old  one,  has 

many  virtues,  and,  were  it  not  for  the  great  diJEficulty  of  keeping  the  parts 

in  position,  would  be  much  more  employed  than  now.  The  flap  is  taken 
from  over  the  biceps,  .with  its  apex  toward  the  shoulder. 
It  is  first  dissected  up,  and  its  extremities  allowed  to 
remain  attached  until  suppuration  is  established,  when 
the  proximal  end  is  separated  and  the  dressing  con- 
tinued until  the  flap  is  well  shrunken  and  the  under 
surface  cicatrized.     It  is  then  applied  to  the  gap  after 

■o     r-oo     T--       c  .1      the  borders   have  been  freshened  (Fisr.  711).      When 
Fig.  738. — \  lew  of  the  .         .  -,■  t      ■  -,  n 

new  nose  from  below   union  IS  completed  the  pedicle  is  cut,  and  the  flap  is 

after  being  sutured   fashioned  so  as  to  relieve  the  deformity  in  the  best  pos- 
into  the  delect.  .,  . 

sibie  manner. 

The  tedious  associations  of  this  operation  do  not  commend  its  employ- 
ment except  in  those  cases  in  which  the  necessary  material  for  repair  can 
not  be  suitably  secured  by  other  methods.  The  cosmetic  qualities  of  the 
integument  of  the  arm  are  not  as  well  suited  to  the  repair  of  facial  deformi- 
ties as  are  those  of  the  integument  of  the  face  itself.  However,  the  facial 
disfigurement  incident  to  transplantation  of  integument  in  the  former  in- 
stances is  avoided  by  this  latter  procedure,  a  fact,  that  will  largely  com- 
pensate for  its  irksomeness.  One  who  contemplates  the  performance  of  this 
method  should  consult  the  experience  of  Sir  William  MacCormac,  as  set  forth 
in  the  Transactions  of  the  Clinical  Society  for  1887,  vol.  xli,  p.  181. 

Osteoplastic  Rhinoplasty. — The  periosteum  has  been  removed  frequently 
from  a  part  of  the  frontal  bone  in  connection  with  the  flap,  and  con- 
signed to  the  gap  with  the  hope  that  the  formation  of  new  bone  might 
occur,  so  as  to  give  solidity  as  well  as  prominence  to  the  new  nose.  The 
removal  of  the  periosteum  from  the  frontal  bone  is  not  by  any  means  devoid 
of  danger.  Osteomyelitis  has  arisen  therefrom,  followed  by  pyaemia  and 
death.  The  periosteum  may  be  used  to  form  a  portion  of  the  flap  first  ap- 
plied in  the  double-flap  method  illustrated  in  Fig.  730.  It  is  true  that  the 
relation  of  its  surfaces  will  be  reversed,  but  this  can  not  change  its  bone- 
producing  value ;  moreover,  if  bone  be  formed,  it  can  be  easily  shaped  by 
manipulation  to  suit  the  proposed  outline  of  the  organ. 

OUier^s  Method. — An  operation  was  performed  some  time  since  by  Oilier 
for  a  deformity  caused  by  the  loss  of  the  alse,  columna,  cartilage,  lobe,  and  a 
portion  of  the  septum,  due  to  lupus.  The  nose  was  not  more  than  an  inch 
long,  due  to  the  arrest  of  development  of  the  ossa  nasi,  to  which  was  attached 
a  strip  of  cartilage.  The  integument  of  the  lip  and  cheeks  had  been  in- 
volved, and  could  not  therefore  be  depended  upon  for  flaps. 

Oilier  commenced  two  diverging  incisions  in  the  median  line  of  the 


PLASTIC  SURGERY. 


591 


forehead  two  inches  ahove  the  c3'el)rows,  and  carried  them  downward  to  a 
fourth  of  an  inch  from  the  outer  sides  of  the  nasal  orifices  (Fig.  739).  The 
upper  portion  of  the  triangular  flap  included  the  corresponding  portion  of 
periosteum  down  to  the  upper  ends  of  the  nasal  hones.  The  dissection  was 
continued  along  the  right  nasal  bone,  omitting  the  periosteum,  down  to  its 
lower  end,  from  which  the  cartilage  was  separated,  though  remaining  at- 
tached to  the  flap.  The  left  nasal  bone  was  separated  from  its  bony  connec- 
tions with  a  chisel,  leaving  it  attached  to  the  flap  by  its  anterior  surface; 
the  cartilaginous  septum  was  then  divided  from  before  backward  and  down- 
ward with  scissors,  and  left  attached  by  its  base  to  the  cutaneous  cartilage, 
that  a  central  support  might  be  provided  for  the  new  structure.  The  whole 
flap  was  then  drawn  downward  until  the  upper  border  of  the  loosened  nasal 
bone  (left)  came  opposite  to  the  lower  border  of  the  right  one,  when  they 


Fig.  739.— Ollier's  method. 


Pig.  740. — Konig's  method. 


were  fastened  together  with  a  metallic  suture.  The  sides  of  the  flap  were 
then  united  to  the  cheek  and  the  frontal  incision  closed  above  its  apex. 

In  this  case,  the  space  remaining  after  the  removal  of  the  left  nasal  bone 
was  filled  by  bone  developed  from  the  periosteum  that  had  been  slid  down 
from  the  forehead. 

Konig's  method  (Fig.  740)  of  treatment  consists  in  separating  the  car- 
tilaginous from  the  bony  portions  of  the  nose  by  a  transverse  incision,  and 
turning  the  end  downward  sufficiently  to  remedy  the  outline  of  the  defect, 
then  filling  in  the  gap  by  an  osteoplastic  flap  taken  from  the  forehead  and 
placed  with  the  bony  surface  upward.  A  second  flap  is  then  raised  from 
the  forehead  and  turned  downward  on  the  former  with  the  cuticular  surface 
upward,  thus  bringing  the  raw  surfaces  in  contact  with  each  other.  Each 
flap  is  united  separately  with  the  borders  of  the  gap.  After  firm  union  is 
established,  the  pedicles  are  cut  and  the  part  is  so  fashioned  as  to  make  an 
acceptably  formed  member. 

Israel  modified  this  operation  by  closing  the  wound  in  the  forehead  at 
once  and  permitting  the  bone  flap  to  granulate  and  heal  by  cicatrization, 
when  the  contraction  following  healing  so  drew  forward  the  skin  of  the 
under  surface  of  the  bone  flap  as  to  cover  two  thirds  of  the  circumference 


592  ■  OPERATIVE  SURGERY. 

of  the  upper  surface  of  the  newly  formed  dorsum.  Quadrilateral-shaped 
flaps  were  then  dissected  from  the  outer  surfaces  of  the  deformed  nose,  also 
from  the  healed  upper  surface  of  the  newly  formed  dorsum,  and  turned  out- 
ward. The  latter  flaps,  with  the  raw  surfaces  upward,  supported,  and 
were  covered  in  by,  the  former,  which  were  united  at  the  median  line  with 
each  other.  If  later  the  bridge  of  the  frontal  flap  be  severed,  and  the  end 
inserted  lower  down,  and  the  flap  itself  have  only  a  ridge  of  bone  at  the 
center  of  its  long  axis,  the  remaining  upper  surface  being  periosteal,  the  cos- 
metic effect  would  be  improved. 

This  variety  of  deformity  has  also  been  relieved  by  attaching  a  finger  to 
the  sides  of  the  nasal  chasm.  The  nail  was  first  removed,  and  the  palmar 
surface  of  the  finger  denuded,  by  the  formation  of  lateral  flaps,  down  to 
the  distal  third  of  the  first  phalanx.  The  finger  was  then  fastened  in  po- 
sition upon  the  freshened  borders  of  the  deformity  by  means  of  sutures 
passed  through  the  lateral  flaps,  and,  when  union  was  sufficient  to  sustain 
the  nutrition  of  the  part,  the  finger  was  amputated  at  the  juncture  of  the 
middle  and  distal  thirds  of  the  third  surgical  phalanx,  and  the  distal  end 
of  the  latter  turned  downward,  to  form  the  end  of  the  nose  and  its  columna. 

The  detail  essential  to  the  proper  description  of  this  operation,  which 
was  done  with  success  by  the  late  Prof.  T.  T.  Sabine,  is  too  extensive  to  be 
considered  here.  A  full  account  of  this  very  interesting  case  can  be  found 
in  the  April  number  of  the  Illustrated  Quarterly  of  Medicine  and  Surgery, 
1882. 

Pancoasfs  Subcutaneous  Method. — The  subcutaneous  method  consists 
in  the  subcutaneous  division  of  the  depressed  tissues,  so  that  they  are  sep- 
arated from  their  bony  connections,  as  was  done  by  Professor  Pancoast  in 
1842.     The  operation  can  be  best  described  in  his  own  language  : 

"  A  long,  narrow-bladed  tenototaiy  knife  was  introduced  on  either  side 
by  a  puncture  through  the  skin  over  the  edge  of  the  nasal  process  of  the 
upper  maxillary  bone.  The  knife  was  pushed  up  under  the  skin  to  the  top 
of  the  nasal  cavity,  and  then  brought  down,  shaving  the  inner  side  of  the 
bony  wall  so  as  to  detach  the  adherent  and  inverted  nose  upon  either  side. 
The  point  of  the  nose  could  now  be  brought  out.  The  nose  still  remained 
adherent  to  the  top  of  the  nasal  chasm.  The  knife  was  a  third  time  intro- 
duced under  the  skin,  in  a  direction  corresponding  nearly  to  the  long  diam- 
eter of  the  orbit  of  the  eyes,  and  the  adhesions  separated  from  the  nasal 
spine  and  the  internal  angular  processes  of  the  os  frontis.  The  soft  parts 
and  the  cheeks  were  loosened,  by  sweeping  the  knife  outward  along  the  sur- 
face of  the  bone,  so  far  as  to  divide  the  infra-orbital  nerve  and  artery  on 
each  side  down  toward  the  median  line,  and  held  together  with  sutures 
passed  through  the  cavity  of  the  nose." 

The  saddle-hack  and  angular  deformities  of  the  nose  are  of  not  infrequent 
occurrence,  and  are  either  of  acquired  or  congenital  origin. 

These  defects  can  be  rectified  by  Konig's  method  (Fig.  740),  and  by 
the  use  of  various  mechanical  expedients.  Martin's  platinum  support 
(Pig.  741),  as  employed  by  Weir  and  others,  is  representative  of  this  class 
of  mechanism. 


PLASTIC  SURGERY.  593 

The  Operation. — A  flap  composed  of  the  upper  lip  and  of  the  nose,  up  to 
the  transverse  center  of  the  nasal  hones,  is  raised  by  free  division  of  the 
mucous  membrane  at  the  gingival  fold,  and  separation  of  the  soft  parts  of 
the  nose  from  the  bony  borders  of  the  meatus  with  a  small  scalpel.  A 
platinum  support  so  constructed  as  to  meet  the  cosmetic  requirements  is 
ancliored  in  position  beneath  the  flap  by  inserting  the  ends  of  the  legs  (c  h) 
into  small  openings  made  into  the  bone  at  tbe  outer  borders  of  the  meatus 
with  a  fine  awl.  The  nasal  flap  is  then  properly  adjusted  to  the  support  {a), 
the  borders  of  the  gingival  fold  are  united  with  fine  sutures,  and  moderate 
pressure  is  applied  to  the  upper  lip  to  secure  prompt  union.  Within  a  week 
or  so  the  post-operative  irritation  disappears,  and  the  patient  will  be  re- 
lieved of  the  deformity  for  a  variable  period  without  material  personal 
discomfort. 

The  introduction  beneath  the  integument  at  the  seat  of  deformity  of  a 
properly  shaped  piece  of  celluloid  is  easy  and  comparatively  satisfactory  in 
the  experience  of  the  author.  The  incision  is  made  in  the  median  line  of 
the  nose  down  to  the  periosteum,  the  soft  parts  are  turned  aside  sufficiently 
to  permit  of  the  introduction  into  the  depression  of  a  celluloid  bridge  so 

shaped  as  to  remedy  the  defect.     The -.:- - 

flaps  are  closed  with  horsehair  sutures     .-/'"  "'"■""" -H>-«ti         ,.■''"■■-":-•, 
and  the   patient  kept   quiet   till   union   '■-■         /        '(f'     .  "Vv 
occurs.  "\       /.i^'iL^'vv 

Properly  shaped  pieces  of  gold,  sil-          ..,.-- — ■'■     10 i  "^^^^ 
ver,  platinum,   rubber,   etc.,   placed   on      /  5?-'   ^■"  J    i  ^■-" ' 

the   bridge   of   the   nose,   or   supported     %S"'~^"'/i^  /      !j^W<i\ 

by  artificial  septa,  are  occasionally  em-     V\'"''/    /'"  J^mf\\       d 

ployed  as  described.  X/'-'i^,      '  ' j^^  ''§      il 

The  Comments. — The  consideration        ]  ';|  ^=J0^    ^ ^^^ 

of  these  expedients  is  introduced  with      /     ''  ^^^^^^ 

the  full  knowledge  of  the  fact  that,  as     / 

yet,  but  temporary  success  from  their    '• -...^.^-.^  ^j  \ 

use  can  be  assured.    However,  even  this  •?..  ,1  X    -^  • 

may  be  of  great  value  in  certain  cases,  piG.  741.— Martin's  nasal  support, 
and  it  is  not  impossible  that  the  im- 
proved technique  of  extensive  practice  may  greatly  increase  the  benefits. 
The  dangers  attending  these  procedures  when  offset  by  aseptic  precautions 
are  of  little  moment.  I  can  not  refrain  from  expressing  the  belief  that  in 
many  of  the  instances  of  non-traumatic,  so-called  nasal  deformities,  the  out- 
line of  the  nose  is  in  accordance  with  the  demands  of  the  architecture  of 
the  face  and  therefore  should  not  be  condemned  for  contributing  its  share 
to  the  "  best  that  can  be  done  under  the  circumstances."  In  such  cases  as 
these  the  morbid  imaginings  of  the  patient  and  the  complaisant  co-operation 
of  the  enterprising  surgeon  may  make  an  agreeable  face  grotesque  liy  the 
fashioning  of  an  incongruous  nose. 

Paraffin  injection  for  the  purpose  of  correcting  nasal  deformities,  espe- 
cially saddle-nose,  appears  to  be  an  established  procedure.  It  ought  to  be 
realized  at  once  that  the  practice  is  not  as  simple  as  it  may  seem  at  first. 


594 


OPERATIVE  SURGERY. 


However^  when  properly  conducted  the  outcome  is  in  most  instances  highly 
satisfactory.  In  each  case  a  thorough  aseptic  technique  should  be  practiced 
in  all  respects.  Both  hard  and  soft  paraffin  are  employed  for  the  purpose, 
the  latter  certainly  appearing  to  be  the  safer  for  reasons  that  will  hereafter 
appear.  The  degree  of  the  melting  point  of  the  paraffin  used  has  much  to 
do  with  the  security  of  the  procedure,  110°  F.  being  the  most  trustworthy.  A 
degree  much  higher  than  this  exposes  the  patient  to  the  dangers  of  pul- 
monary embolism,  because  of  the  diffluence  of  the  paraffin,  and  to  impaired 
integrity  of  the  skin  because  of  the  undue  temperature.  If  lower  than  110° 
F.,  its  hardness  may  plug  the  needle,  interfere  with  the  proper  molding,  etc. 
The  material  suitable  to  melt  at  this  degree  (110°  F.)  can  now  be  secured 

in  shops,  for  immediate  use,  in 
sealed  sterile  tubes.  The  injection 
can  be  made  with  the  antitoxine 
syringe  or  with  one  designed  for 
the  purpose  (Fig.  742),  and  in 
either  case  the  needle  should  be 
stout,  sharp,  and  with  a  sufficient 
lumen  to  permit  the  ingredients 
to  "  emerge  from  the  needle  in  a  thread-like  string,"  "  easily  molded  and 
quite  capable  of  forming  an  embolus  "  (Smith),  when  properly  cooled. 

The  Operation. — Secure  anaesthesia  at  the  seat  of  prepared  puncture 
with  a  drop  or  two  of  a  two-per-cent  solution  of  cocaine  if  required;  intro- 


PiG.  742. — Smith's  laai'affin  injection  syringe. 


Fig.  743.— Deformity  of  nose. 


Fig.  744. — Deformity  of  nose  rectified 
by  paraffin  injection. 


duce  the  needle  at  the  selected  point  into  the  subcutaneous  tissue  just  be- 
neath the  skin,  slightly  beyond  the  deformity  (Fig.  743);  begin  the  injec- 
tion slowly,  continuing  it  with  frequent  interruptions  to  permit  the  proper 


PLASTIC  SURGERY. 


595 


molding  of  the  drug,  withdrawing  the  needle  gradually  as  the  injection 
proceeds;  finally,  when  a  sufficient  amount  is  introduced,  withdraw  the 
needle  entirely,  closing  the  point  of  puncture  with  collodion.  When  proper 
molding  is  assured  (Fig.  7-i4),  hasten  the  hardening  by  ice-water  applica- 
tions or  by  a  mild  use  of  the  ether  spray. 

The  Dangers. — With  the  exercise  of  care  in  the  preparation,  introduc- 
tion, and  control  of  the  agent  little  fear  of  unfavorable  outcome  need  be 
felt;  but  indifference,  carelessness,  or  ignorance  in  the  use  may  be  followed 
by  either  toxic  absorption,  excessive  inflammatory  action,  loss  of  tissue 
from  infection,  abscess  and  overheating  of  the  drug,  pressure  necrosis,  air 
or  paraffin  embolism,  deformity  from  too  little  or  too  great  amount  of 
the  injection  and  from  its  going  astray ;  its  absorption,  its  interference  with 
muscular  action  of  the  ala,  and  the  effects  of  an  improper  melting  point. 

The  Remarks. — The  proper  temperature  can  be  secured  by  dropping 
the  loaded  syringe  into  water  of  the  requisite  warmth,  rememlDering  that 
the  needle  cools  sooner  than  the  barrel  of  the  instrument.  Special  syringes 
kept  at  suitable  temperature  by  electricity  or  hot  water  are  devised;  also 
syringes  are  covered  with  gutta  percha  for  a  similar  reason.  If  the  needle 
only  be  dipped  in  hot  water  for  a  few  seconds  before  use,  hardening  of  the 
drug  en  route  will  be  obviated.  If  the  fingers  be  pressed  along  the  ridge 
of  the  nose  to  limit  the  spread,  no  danger  of  invading  the  ala  or  orbital 
region  will  occur.  If  blood  can  be  drawn  into  the  needle  after  injecting 
cocaine,  the  paraffin  should  not  be  introduced  at  that  situation. 

The  Results. — Paget  *  reports  forty-three  cases  done  for  deformed  noses 
with  no  accident,  and  a  great  majority  with  a  satisfactory  outcome. 

The  deformity  of  twisted  nose  (Fig.  744  a)  is  corrected  (Fig.  744  h) 
by   cutting   upward   subcutaneously   with   a   fine   sharp  thin    chisel   and 


Fig.  744  a. — A  twisted  na- 
sal deformity. 


Fig.  744  h. — The  twisted 
nasal  deformity  corrected. 


Fig.  744  c. — An  angular  na- 
sal deformity. 

Fig.  744  cZ.— The  deformity 
corrected. 


mallet  the  bony  connections  between  the  nasal  bones  at  either  side  and 
the  nasal  process  of  the  superior  maxilla  and  adjusting  the  parts. 

The  angular  nose  can  ])e  made  shapely  often  by  the  removal  of  the  super- 


Lancet,  Way  16,  1903. 


596  OPERATIVE  SURGERY. 

abundant  tissue  at  the  seat  of  deformity  with  a  sharp  chisel  or  knife 
(Figs.  744  c  and  d).  The  incision  for  this  purpose  is  located  in  the  median 
line  of  the  deformity,  and  is  of  proper  dimensions  to  permit  exposure  of 
the  enlargement  without  undue  injury  of  the  contiguous  soft  parts.  After 
removal,  the  incision  is  closed  in  the^  usual  manner. 

Disfigurement  of  the  nose  dependent  on  morbid  growths  frequently  re- 
quires treatment.  So  long  as  the  bony  and  cartilaginous  framework  of  the 
nose  remains  intact,  the  removal  of  the  disfigurement  and  the  grafting  of 
the  raw  surface  resulting  therefrom  can,  in  the  great  majority  of  cases,  be 
carried  to  a  satisfactory  issue,  as  in  the  following  case : 

This  patient  came  under  the  observation  of  the  writer  while  suffering  from  a  large 
and  highly  vascular  angioma  involving  nearly  all  of  the  superficial  structures  of  the 
nose  and  the  columna  (Fig.  745).  The  growth  began  in  infancy  as  a  "mother's 
mark"  and  had  increased  rapidly  in  size  during  the  last  three  or  four  years.  Re- 
peated severe  haemorrhages  had  occurred  from  an  ulcerating  point  on  the  surface, 
which  greatly  weakened  the  patient.  The  following  plan  of  treatment  was  carried 
into  effect.  The  circulation  was  controlled  at  either  side  of  the  nose  by  long-bladed 
forceps  so  applied  as  to  compress  the  upper  lip  and  cheek ;  that  of  the  frontal  vessels 
was  controlled  by  direct  external  pressure.  The  growth  was  split  in  the  median  line 
down  to  the  bony  and  cartilaginous  framework  the  entire  length  with  a  scalpel,  and 
the  respective  halves  were  turned  aside  with  a  blunt  instrument  carried  along  the  bony 
and  cartilaginous  tissues  to  the  outer  limits  of  the  growth,  where  they  were  ligatured 
with  the  cobbler's  stitch  and  cut  away  with  cautery.  The  alte  were  not  involved  suf- 
ficiently to  require  removal.  After  the  cutting  away  of  the  ligatures  the  granulating 
surface  was  covered  with  skin  grafts,  and  quickly  healed  (Fig.  746).  The  remaining 
points  of  angiomatous  structure  were  treated  with  galvano-puncture. 

Harelip. — The  deformity  of  harelip  constitutes  a  large  proportion  of 
the  congenital  defects  calling  for  operations  upon  the  face. 

The  operations  for  its  relief  can  be  practiced  at  any  age,  but  the  best 
time  is  as  soon  after  birth  as  the  infant  becomes  sufficiently  well  educated  to 
take  its  food  and  enabled  ,to  bear  the  loss  of  blood.  If  the  infant  be  plump 
and  robust  operation  can  be  practiced  earlier  than  if  weak  and  puny.  The 
exceptions  are  rare  when  operation  is  not  admissible  at  four  months  of  age. 
The  complete  control  of  the  patient  during  the  operation  is  important. 

For  this  purpose  an  ansesthetic  should  be  given,  chloroform  being  usually 
selected.  The  arms  of  the  patient  are  placed  at  the  sides  and  held  in  position 
by  a  napkin  surrounding  the  body  and  pinned  sufficiently  tight  to  prevent 
their  withdrawal,  being  careful,  however,  not  to  constrict  the  chest  during 
anaesthesia.  One  assistant  takes  the  child  in  his  lap,  another  stands  behind 
him  and  holds  the  infant's  body.  The  head  of  the  patient  is  lield  by  the 
hands  of  the  first  assistant,  so  as  to  enable  him  to  control  the  movements  of 
the  head,  and  likewise  the  circulation  in  the  facial  arteries  with  the  fingers, 
and  at  the  same  time  to  bend  the  head  forward,  that  blood  may  escape  from 
the  mouth.  He  can,  if  necessary,  also  administer  the  anaesthetic  with  a  small 
sponge  held  between  the  index  fingers.  The  success  of  the  operation  will 
depend  in  a  very  large  degree  upon  the  entire  absence  of  tension  of  the 
parts  when  placed  in  position.  To  prevent  tension,  it  is  often  necessary  to 
separate  the  lip  and  cheeks  to  a  considerable  extent  from  their  bony  con- 


PLASTIC  SURGERY. 


597 


Fig.  745. — Before  operation  (i  size). 


Fig.  746. — After  operation  (^  size). 


598 


OPERATIVE  SURGERY. 


nections.  In  some  instances,  owing  to  the  difficulties  of  the  case,  the  loss 
of  blood  will  be  considerable,  unless  every  precaution  be  taken.  The  cor- 
onary vessels  usually  supply  the  bleeding  points,  but  they  can  be  easily  con- 
trolled by  grasping  the  lip  at  both  sides  of  the  incision  between  the  thumbs 
and  fingers.  By  this  procedure,  the  same  force  that  puts  the  part  upon 
the  stretch  also  cheeks  the  fiow  of  blood.  As  the  fingers  of  the  assistant 
often  hinder  the  operator,  especially  if  the  cleft  be  large,  their  action  can 
readily  be  supplemented  by  passing  through  the  lip,  at  each  side  of  the 
proposed  cut,  a  strong  silk  ligature,  which,  when  looped,  makes  it  possible 
to  keep  the  parts  on  the  stretch  without  inconvenience,  and  which  can  be 
so  placed  that  when  made  tense  the  coronary  vessels  will  be  compressed. 
Either  Milne's  artery  compression  forceps  or  Langenbeck's  serre-fines  (Fig. 
103)  will  control  the  hemorrhage  admirably  if  fixed  at  the  angle  of  the 
mouth  on  each  side.    If  the  blades  of  the  ordinary  dressing  forceps  be  sur- 


FiG.  747. — Instruments  employed  in  operation  on  harelip,  a.  Double-edged  and  blunt- 
pointed  knives,  b.  Thumb-  and  mouse-toothed  forceps,  c.  Sharp-pointed  curved, 
and  blunt-pointed  straight  scissors,  d.  Harelip  pins  (not  frequently  used  now). 
e.  Langenbeck's  serre-fines.    /.  Forcipressure  forceps. 

rounded  by  adhesive  plaster  and  closed  upon  the  lip  by  rubber  bands  passed 
around  the  handles,  a  useful  substitute  will  be  had  for  the  instruments  just 
mentioned  (Fig.  747).  The  borders  may  be  pared  with  a  sharp-pointed 
scalpel,  strong  scissors,  or  the  triangular  cataract  knife;  the  latter  is  very 
useful  for  this  purpose.  It  is  not  permissible  to  sacrifice  certain  of  the  par- 
ings taken  from  the  free  borders  of  the  cleft,  except  in  cases  with  but  little 
deformity;  they  therefore  should  remain  attached  and  be  utilized  in  filling 
in  the  gap,  this  being  the  only  satisfactory  manner  of  avoiding  the  occur- 
rence of  the  objectionable  notch  often  seen  after  operations  for  harelip.  The 
pins  and  sutures  should  perforate  the  flaps  at  least  a  third  or  fourth  of  an 
inch  from  the  borders  of  the  wound,  and  even  farther,  if  there  be  any  degree 
of  tension.  One  or  two  of  either  will  be  sufficient  in  the  majority  of  cases. 
Neither  pins  nor  sutures  are  carried  entirely  through  the  flaps,  but  are 
passed  near  to  their  under  surface.    The  sutures  may  be  inserted  nearer  to 


PLASTIC  SURGERY.  599 

the  edges  of  the  wound  than  the  pins,  and  in  sufficient  number  to  properly 
connect  the  lips.  The  pins  are  removed  within  two  or  three  days,  the 
sutures  remain  longer.  If  nlceration  around  the  pins  be  threatened,  they 
should  be  removed  after  others  have  been  inserted  at  new  points  to  receive 
any  strain  that  may  be  present. 

The  operation  for  all  forms  of  harelip  can  be  divided  properly  into 
three  steps. 

The  First  Step. — In  the  first  step  the  possibility  of  the  occurrence  of  tension 
with  union  of  the  borders  of  the  defect,  is  combated  by  freely  separating 
the  lip  and  perhaps  also  the  cheek  backward  and  upward  from  the  bone  at 
either  side  with  scissors  or  scalpel.  A  restraining  ala  should,  be  separated 
from  its  bony  connections  in  a  similar  manner.  Unusual  bony  projection 
should  be  remedied  by  instrumental  or  manual  force  at  this  time. 

The  Second  Step. — The  second  step  consists  in  making  the  borders  of 
the  cleft  tense  with  mouse-tooth  forceps  and  cutting  them  of  equal  thick- 
ness with  a  small,  sharp-pointed  scalpel,  or  with  scissors,  in  accordance  with 
the  plan  of  the  operation.  When  possible,  the  preparatory  cutting  should 
be  planned  so  as  to  utilize  the  parings  in  the  final  closure,  thus  lessening 
tension  and  obviating  a  notched  vermilion  border.  The  performance  of 
this  step  is  attended  with  more  or  less  haemorrhage,  which  can  be  easily 
controlled  by  pressure  at  either  side  of  the  lip  with  the  fingers,  by  Langen- 
beck's  serre-fines,  or  properly  adjusted  traction  sutures. 

The  Thi7'cl  Step. — The  third  step  relates  to  the  approximation  of  the 
divided  borders.  The  borders  are  apposed  by  forward  pressure  directed 
from  the  cheeks  by  the  assistant.  A  single,  long  harelip  pin  is  then  carried 
through  the  flaps  at  the  center  of  the  lip  at  considerable  distance  from  the 
borders,  and  its  influence  supplemented  with  a  figure-of-eight  aseptic  cotton- 
yarn  suture  applied  moderately  tight.  The  vermilion  borders  of  the  flaps 
are  now  carefully  adjusted  and  united  with  silkworm-gut  sutures  ;  the  upper 
border  is  similarly  treated.  The  pin  is  then  withdrawn  and  the  intervening 
space  suitably  joined  with  similar  sutures.  Two  or  three  sutures  of  fine 
catgut  or  silk  are  next  applied  to  the  vermilion  border  and  mucous  mem- 
brane. If  tension  be  marked,  the  pin  or  needle  employed  in  the  primary 
adjustment  of  the  borders  can  again  be  used,  and  its  influence  supplemented 
with  the  cotton-yarn  suture,  until  danger  of  ulceration  at  the  points  of 
perforation  is  feared.  If  still  further  restraint  be  needed,  the  pin  may  be 
reapplied  at  a  different  site. 

The  wound  is  then  dressed  with  iodoform  or  acetanilid  and  still  further 
supported  if  necessary  with  adhesive  strips  which  are  applied  far  back  on 
either  cheek,  drawn  forward,  crossed,  and  attached  to  the  opposite  sides  simul- 
taneously. If  there  be  a  cleft  in  the  hard  palate  also,  the  application  of 
iodoformized  collodion  to  the  surface  of  the  wound  will  prevent  the  food 
and  buccal  discharges  from  soiling  its  borders.  The  wound  is  redressed  at 
the  end  of  the  second  or  third  day.  The  sutures  are  removed  successively 
from  the  fifth  day  on,  the  lip  being  fortified  by  adhesive-plaster  restraint 
over  the  site  of  removal  if  advisable.  When  union  fails  in  part  or  entirely, 
the  borders  ought  still  to  be  held  as  nearly  together  as  possible,  during  such 


600 


OPERATIVE  SURGERY. 


a  degree  of  repair  as  may  take  place.  An  attempt  to  remedy  a  secondary 
defect  of  this  sort  by  operation  should  not  be  made  until  some  time  has 
elapsed,  in  order  that  the  borders  shall  again  become  well  healed,  and  the 
condition  of  the  patient  improved.  In  all  instances,  carefully  avoid  closure 
of  the  nostrils  unless  the  patient  is  able  to  breathe  easily  through  the  mouth 
when  they  are  obstructed. 

Single    Harelip. — Single  harelip  can  be  treated  by  superficial  or  deep 
paring  with  direct  union  of  the  borders  of  the  cleft  either  by  the  single-  or 


*    \ 


■"V^^- 


FiG.  748. — Mirault's  method  of  freshening  and  suture. 

double-flap  methods.  The  simplest  method  consists  in  paring  with  a  knife 
the  borders  of  the  cleft,  loosening  freely  the  labial  connections  to  the  bones, 
and  bringing  the  edges  directly  into  contact  with  each  other.  Unless  the 
operation  is  carefully  performed  this  method  is  often  followed  by  a  notch 
at  the  border  of  the  lip  where  the  flaps  are  joined. 

The  Single-flaj}  Method  (Mirault)  (Fig.  748). — Draw  down  both  borders 
of  the  cleft  and  freely  sever  their  connections  with  the  bone ;  pare  the  bor- 
der of  the  longer  portion,  and  make  the  flap  from  the  shorter;  turn  down 
the  flap,  and  approximate  and  unite  the  borders  as  before  described. 

The  Douhle-flap  Method  (Malgaigne). — Pass  a  silk  ligature  through 
each  angle  of  the  fissure;  divide  the  sublabial  connections;  make  one  side 


Fig.  749. — Malgaigne's  method  of  fieshening  and  suture. 

tense ;  transfix  it  near  the  border  of  the  fissure,  and  cut  upward  to  and  over 
the  apex  of  the  same;  repeat  the  operation  on  the  opposite  side  of  the 
fissure ;  draw  both  flaps  thus  formed  downward,  bringing  their  cut  surfaces 
in  contact  with  each  other  (Fig.  749) ;  close  the  cleft  with  a  pin  or  suture 
passed  near  to  the  vermilion  border,  and  with  another  above  if  necessary; 
unite  the  everted  flaps  by  a  fine  silken  thread  or  horsehair;  cut  off  their 
extremities  obliquely,  leaving  enough  tissue  to  form  a  prominent  projection 


PLASTIC  SURGERY. 


601 


at  the  margin  of  the  lip  in  order  to  obviate  the  formation  of  a  notch.  If 
the  cleft  be  shallow  the  flaps  should  remain  connected  above  and  be  turned 
downward  and  united  as  before. 


Fig.  750. — Hagedorn's  method  of  freshening  and  suture. 

Hagedorn's  Method  (Fig.  750). — Loosen  the  lip  and  fix  the  borders  of 
the  cleft  with  traction  sutures;  make  a  curved  incision  on  either  side  by 
transfixion  from  above  downward  along  the  outer  limit  of  the  convex  muco- 


FiG.  751. — Simon's  method. 


cutaneous  borders  of  the  cleft  to  near  the  vermilion  border  of  the  lip,  the 
incision  in  the  major  border  of  the  cleft  being  slightly  the  longer;  from 
near  to  the  lower  end  of  the  shorter  incision  and  from  the  lower  end  of 
the  longer  one,  two  short  incisions  are  made,  the  one  passing  horizontally 
outward,  and  the  other  obliquely  upward  and  outward.  Short  incisions 
are  then  made  outward  from  the  free  borders  of  the  cleft  to  the  long 

ones.      The   upper  extremi- 
/  '$  -1       ||  iji'^  ties  of  the  primary  incisions 

are  united  by  short  trans- 
verse incisions,  and  the  mar- 
ginal tissue  is  removed.  The 
borders  are  brought  in  con- 
tact and  united  with  silk- 
worm gut. 

Simons  Method  (Fig. 
751). — Simon  made  an  L-shaped  incision  in  the  border  opposite  the  median 
one,  and  a  recumbent  ■<-shaped  incision  at  the  median  border  (A) ;  the  tis- 
sues were  removed,  the  upper  limits  of  the  freshened  borders  were  united 
first,  and  the  remaining  portions  subsequently,  in  the  usual  manner. 
40 


Fig.  752. — Dieflfenbach's  method,  liberating  incisions. 


602 


OPERATIVE  SURGERY. 


Dicffenbacli's  Method. — In  cases  with  wide  and  complete  clefts,  liberat- 
ing incisions  passing  around  the  alffi  (Fig.  752)  and  outward  for  a  short 
distance  into  the  cheeks,  or  made  transversely  directly  below  the  nose,  are 
of  much  service  in  securing  ready  and  proper  coaptation  of  the  borders  of 
the  cleft.  These  incisions  enable  the  surgeon  to  make  more  readily  the 
needed  detachment  of  the  lip  from  the  jaw. 

Konig's  Method. — Konig  removes  the  borders  of  the  cleft  entirely,  and 
then  forms  a  flap  at  either  side  by  means  of  incisions  directed  downward 
and  outward  from  near  the  middle  points  of  the  vertical  ones  (Fig.  753). 


Fig.  753. — Konig's  method  of  freshening  and  suture. 

The  incision  at  the  outer  side  of  the  cleft  is  somewhat  the  longer.  The 
flaps  are  tilted  downward  in  sewing,  thus  obviating  the  liability  of  a  notch 
in  the  vermilion  border. 

Giraldes's  Method. — Giraldes's  method  is  principally  employed  when 
the  deformity  extends  into  the  nasal  cavity,  and  the  flaps  are  constructed 
so  as  to  provide  a  floor  to  its  entrance  (Fig.  754).  When  the  flap  (1)  is 
carried  upward  to  repair  the  floor  of  the  nostril,  the  angle  of  this  flap 
is  then  brought  in  contact  with  the  angle  at  the  upper  extremity  of  the 


Pig.  754. — Giraldes's  method  of  freshening  and  suture. 

border  (3),  the  cut  surfaces  thus  brought  into  apposition  being  of  a 
similar  length  (3,  4).  The  freshened  border  (5)  then  comes  in  contact 
with  (2)  the  point  of  the  flap  resting  upon  the  undermost  cut,  in  which 
position  the  margins  are  united.  The  cuticular  border  of  the  end  of  the 
inner  flap  (1)  is  partially  removed  so  that  a  freshened  wedge  of  tissue 
is  inserted  at  the  horizontal  incision  of  the  flap.  This  is  an  admirable 
operation,  and  can  be  employed  on  all  occasions  where  extensive  deformity 
exists. 


PLASTIC  SURGERY. 


603 


Fig.  755. — Double  hai-elip. 


Double    Harelip  (Simple). — Pare   tlie   central   portioc    (Fig.    755)    on 
both  sides;  make  lateral  flaps  with  tlieir  attachments  below  at  the  outer 
borders  (a  b) ;  liberate  the  labial  con- 
nections,   and   approximate   the   raw 
surfaces  by  the  aid  of  silkworm-giit 
sutures. 

Complicated  Harelip. — Harelip  is 
often  complicated  b}*  a  fissure  through 
the  alveolar  process,  which  sometimes 
extends  to  the  hard  palate,  and  even 
beyond,  and  through,  the  soft  parts.  For  a  time  before  the  operation,  it  is 
well  for  the  parents  or  nurse  to  make  gradual  pressure  upon  the  more 
prominent  bony  portion,  combined  with  outward  traction  on  the  depressed 
side,  endeavoring  thereby  to  cause  the  alveolar  arch  to  assume  as  nearly  as 
possible  a  normal  outline.  A  reasonable  degree  of  patience  in  making  these 
painless  manipulations  will,  in  time,  effect  a  more  satisfactory  result  tlian 
the  application  of  sudden  force  by  means  of  forceps.  The  practice  of 
forcing  the  alveolar  extremities  into  position,  paring  and  wiring  them,  is 
pernicious,  since  to  do  so  still  further  shortens  the  outline  of  the  arch  of 
the  superior  maxilla,  and  does  not  result  in  a  bony  union  of  the  extrem- 
ities. The  gentle  but  constant  traction  exerted  by  the  united  lip  will  in 
time  as  certainly  reduce  the  projecting  bone  to  the  proper  place  as  the 
more  vigorous  measures. 

It  is  better  to  allow  the  deformity  of  the  hard  parts  to  remain  un- 
molested until  the  teeth  appear,  when  the  outline 
of  the  biting  surface  of  the  upper  may  be  compared 
with  that  of  the  lower  jaw,  and  made  to  meet  it 
l3y  rectifying  the  upper,  and  introducing,  if  neces- 
sarv,  additional  teeth  upon  a  plate  to  fill  any  gap 
in  the  biting  surface.  Giraldes's  method  (Fig.  754) 
offers  the  best  means  of  closing  the  fissure  in  the 
lip  in  these  cases. 

The  fissure  may  he  doiible,  and  involve  both  the 
hard  and  soft  parts,  back  to  and  through  the  soft 
palate.  The  intermaxillary  bone  in  these  cases  may 
project  freely,  and  even  be  adherent  to  the  soft 
parts  covering  the  end  of  the  nose  (Fig.  756).  If  such  be  the  case,  division 
of  the  vomer  may  be  practiced,  after  which  the  projecting  portion  is 
forcibly  pressed  into  position,  and  the  soft  parts  are  united,  as  in  the 
simpler  forms;  except,  perhaps,  it  may  not  be  prudent  to  unite  both  sides 
•simultaneously  for  fear  of  causing  too  great  traction. 

The  Management  of  a  Projecting  Intermaxillary  Bone. — ]\Iany  plans 
to  remedy  an  excessive  projection  of  this  bone  have  been  devised.  Blan- 
din  advised  the  free  removal  of  a  properly  estimated  triangular-shaped 
piece  from  the  vomer  (Fig.  757).  But  attendant  haemorrhage  and  failure 
of  union  caused  many  surgeons  to  advise  rather  its  subperiosteal  resection. 
The  subperiosteal  method  is  readily  accomplished  by  raising  the  periosteum 


Fig. 


756. — Complicated 
harelip. 


604 


OPERATIVE  SURGERY. 


and  superimposed  nmcous  membrane  simultaneously  with  a  delicate  peri- 
osteotome  through  incisions,  made  along  either  side  of  the  edge  of  the 


vomer.     After   a  proper  extent  of 


Fig.  757. — Projecting  intermaxillary  bone. 
Blandin's  operation,  triangular  incision. 
Rose's  operation,  dotted  line. 


denudation,  the  elevated  tissues  are 
drawn  aside  by  retractors,  and  the 
triangular  section  is  made  with  strong 
scissors;  the  projecting  portion  is 
forced  into  place,  and  the  soft  parts 
are  properly  retained  by  suitably  ar- 
ranged intra-nasal  and  supra-labial 
restraint.  Rose  advised  that  a  single 
vertical  incision  be  made  through 
the  bone  after  denudation. 

When  the  protruding  portion  is 
connected  to  the  nose,  it  should  be 
separated  with  care  or  the  columna 
will  be  impaired. 


Bardeleben  divided  the  bone  after  denudation  for  about  three  quarters  of 
an  inch  and  then  reduced  the  deformity  with  but  trivial  bleeding.  The 
reduction  of  the  def ormit}^  then  causes  an  overlapping  of  the  borders  of  the 
vomer,  which  is  followed  by  union  of  the  apposed  surfaces. 

The  Operation  for  Double  Harelip  (Complicated). — After  proper  reduc- 
tion of  the  intermaxillary  bone,  the  central  strip  of  integument  is  pared  at 
the  margins  so  as  to  form  a  quadrilateral-shaped  flap.  After  this  is  ac- 
complished the  outer  borders  of  the  cleft  are  pared,  the  lower  portions  of 
which  are  provided  with  flaps  similar  to  those  in  Malgaigne's  operation. 
The  borders  of  the  upper  portions  are  removed  entirely.  The  attached  flaps 
are  turned  downward,  trimmed,  and  properly  united  with  each  other,  coinci- 
dent with  the  proper  adjustment  of  the  remaining  corresponding  borders 
of  the  wound  (Fig.  758).     The  author  in  two  cases  of  this  character  has 


Pig.  758. — Operation  for  double  harelip. 

turned  outward  the  parings  of  the  vertical  borders  of  the  central  segment, 
and  inserted  the  distal  ends  respectively  into  transverse  incisions  made  one 
beneath  either  ala,  as  in  Griraldes's  method.  This  plan  provides  a  good  floor 
to  the  entrance  of  the  nostrils. 

Hagedorns  Method  (Fig.  759). — Hagedorn's  method,  although  not  so 
simple  as  the  preceding  one,  requires  no  special  description  to  explain  it. 
The  teatlike  projection  at  the  median  line  of  the  upper  lip  is  longer  than 
necessary. 


PLASTIC  SURGERY. 


605 


Owens  Method. — In  this  operation  the  prolabium  and  the  incisive 
bone  are  removed  and  thick  flaps  are  cut  as  follows:  On  the  right  the 
incision  c  d  e  (Fig.  760,  a)  is  made  and  the  fragments  removed.     On  the 


Fig.  759. — Hagedorn's  operation  for  double  harelip. 

left  the  incision  f  h  is,  made  and  the  respective  borders  united  so  as  to 
bring  a  to  e  (Fig.  761),  h  to  d  and  /  to  c,  when  the  sutures  are  introduced 
and  tied. 

The  After-treatment. — In  such  cases  as  these  care  must  be  taken  not 
to  obstruct  the  nasal  openings,  hence  cumbersome  dressings  should  be 
avoided,  and  the  wound  treated  with  iodoformized  collodion  supplemented 
with  a  scanty  gauze  covering.  The  mouth  and  the  nostrils,  especially 
the  latter,  should  be 
kept  well  cleansed 
and  free  from  all  dis- 
charges, food,  etc.  In 
other  respects  the 
treatment  is  similar 
to  that  of  the  preced- 
ing cases. 

The  Results. — 
The  rate  of  mortality 
depends  on  the  se- 
verity of  the  operation,  age,  condition,  and  environment  of  the  patient,  etc. 
About  five  per  cent  die  in  the  first  two  weeks  after  operation,  and  about 
forty  to  fifty  per  cent  during  the  first  year.  However,  the  operation  can 
not  alone  be  blamed  for  this  high  rate. 

Cheiloplasty  is  an  operation  directed  to  the  cure  of  deformities  of  the 
lips  dependent  on  disease  or  congenital  defects.  The  general  technique  of 
cheiloplasty  differs  but  little  from  that  of  harelip.  The  former  operation  is 
addressed  mainly  to  the  defects  of  adults  and  those  amenable  to  discipline. 
Therefore,  the  requirements  of  cleanliness  are  better  observed,'  and  the  final 
results  are  correspondingly  improved. 

Deformity  of  Lower  Lip.  The  V  Incision. — The  V  incision  i?  employed 
for  the  removal  of  epitheliomata  or  other  morbid  growths  that  do  not  re- 
quire the  elimination  of  more  than  one  third  of  the  lip.  The  whole  thick- 
ness of  the  lip  is  divided,  the  length  of  the  arms  of  the  V  being  increased 
proportionately  to  the  width  of  its  base.     The  usual  liberating  incisions  may 


Fig.  760. — Owen's  operation. 
Making  flaps. 


Fig.  761. — Owen's  operation. 
Flaps  united. 


606 


OPERATIVE  SURGERY. 


be  required.    The  cut  surfaces  are  united  by  the  same  means,  and  cared  for 
in  the  same  manner,  as  in  operations  for  harelip  (Fig.  762). 

Grant's  Method. — This  incision  can  be  employed  in  place  of  the  V- 
shaped  incision,  especially  when  the  gap  following  the  latter  is  too  wide 


Fig.  763. — Grant's  operation.     Flap  formed. 


Fig.  762. — V  incision  ;  union 
with  harelip  pins. 


Fig.  764. — Grant's  operation.    Flap  united. 


for  the  purposes  of  ready  adjustment  with  satisfactory  cosmetic  effect ;  also 
the  oblique  incisions  h  e  and  c  f  (Fig.  763)  can  be  extended  beneath  the 
chin,  affording  opportunity  to  remove  diseased  lymphatics  (Fig.  763). 

Blasius's  Method.— In  this  method  the  growth  involves  more  or  less  of 
the  lower  lip.  After  removal  of  the  growth,  the  semilunar  incisions  (Fig. 
765)  are  made,  their  length  being  regulated  by  the  freedom  of  the  subse- 
quent adjustment  of  the  flaps.  If  the  morbid  process  will  permit  (Fig.  765), 
sufficient  mucous  membrane  may  be  saved  or  separated  and  transferred 


Fig.  765. — Blasius's  method  for 
removal  of  lower  lip. 


Fig,  766. — Blasius's  method  for  removal 
of  lower  lip.     Flaps  united. 


by  sliding  from  the  inner  surface  so  as  to  cover  the  oral  margin,  thus  pro- 
viding a  suitable  vermilion  border  when  sutured  to  the  integumentary  edge. 
The  Horizontal  Incision. — When  the  morbid  process  does  not  involve 
the  free  border  of  the  lip,  it  can  be  removed  by  an  oval  incision  horizontally 


PLASTIC  SURGERY. 


607 


situated,  and  the  gap  closed  in  the  usual  manner  (Fig.  767).  If  the  space 
be  too  large  to  admit  of  closure,  it  can  l)e  left  to  heal  by  granulation,  or 
be  remedied  by  the  sliding  process,  either  with  or  without  parallel  or 
transverse  incisions.  .     _-^artaaam!h^__^  ....  .._.  \ 

the  morbid  growth  involves  Fig.  7<17.-^A  nu'thod  of  removul  of  suicrli' i  tl  epithe- 
the  whole  or  half  of  the  lip,  ''""'''^  «^'  ^'P- 

the  broad-based  V  incision  is  supplemented  by  transverse  ones  extending 
outward  from  each  angle  of  the  mouth  a  sufficient  distance  to  admit  the 
easy  joining  of  the  V  borders  after  the  tissues  have  been  freely  liberated 
from  their  bony  attachments  (Figs.  768  and  769).     If  difficulty  be  expe- 


FiG.  768. — Celsus's  method.    Flap  formed.         Fig.  769. — Celsus's  method.    Flap  united. 


rienced  in  sliding  the  flaps,  it  may  be  overcome  by  making  short  vertical 
incisions  through  the  cheek  at  the  outer  extremities  of  the  horizontal  ones 
(e,  e).  The  most  ingenious  feature  of  this  method  consists  in  dividing 
the  buccal  mucous  membrane  at  least  a  fourth  of  an  inch  above  the  in- 
cision made  through  the  cheek  and  parallel  with  it,  so  that  when  the  out- 
Avard  cuts  are  completed,  and  the  parts  Joined  in  the  median  line  to  form 
the  lip,  the  raw  Ijorder  of  the  latter  can  be  covered  by  turning  the  pro- 
cesses of  mucous  membrane 
over  it,  thereby  forming  an 
:  excellent  vermilion  border. 
J  The  angles  of  the  mouth 
'  are  also  to  be  formed  by 
stitching  the  memlirane  and 
buccal  cuts  to  each  other. 

Estlander's  Method. — 
Estlander's  method  is  effi- 
cient when  the  loss  of  lip 
is  partial,  located  at  one 
side,  and  encroaches  on  the  skin  over  the  chin  (Fig.  770).  A  triangular  flap, 
having  the  coronary  artery  in  the  pedicle,  is  turned  downward  from  the 


Fig.  770.— Partial  eheiloplasty  (Estlander). 


608 


OPERATiyE  SURGERY. 


cheek  and  fitted  to  the  gap  below  prepared  for  its  reception.    This  method 
provides  a  vermilion  border  and  results  in  a  prompt  and  satisfactory  cure. 

Langenbeck's  Method  (Circular). — Langenbeck's  method  is  addressed  to 
a  defect  limited  to  any  part  of  the  lower  lip  not  exceeding  half  its  length 
(Fig.  771),  and  involving  the  movable  portion  only.  The  incision  passes 
along  the  inferior  limit  of  the  defect,  and  is  extended  outward  at  either 
side  around  the  angles  of  the  mouth  and  into  the  upper  lip  to  a  distance 
conforming  to  the  width  of  the  gap  to  be  closed.  The  separated  portions  of 
the  lip  are  loosened  and  so  adjusted  as  to  fill  the  gap  when  united  by 


-i-^-'Mr^Hr 


Fm.  771.— Cheiloplasty  with 
displacement  of  the  border 
of  the  lip  (Langenbeck). 


Fig.  772. — Cheiloplasty  with  the  formation  of  two  flaps 
from  the  cheeks  (Bruns). 


sutures  below.  The  remaining  portion  of  the  gap  is  closed  with  sutures, 
always  remembering  to  begin  the  suturing  opposite  the  angles  of  the  newly 
formed  mouth,  that  the  oval  outline  may  be  maintained. 

Bruns's  Method. — Bruns's  method  is  applicable  to  the  restoration  of 
the  entire  lower  lip  (Fig.  772).  After  the  gap  is  properly  fashioned,  two 
quadrilateral  flaps,  comprising  the  thickness  of  the  cheek,  are  formed,  one 
at  either  side  of  the  mouth.  These  flaps  are  loosened  and  turn  down- 
ward into  the  gap,  to  the  borders  of  which  they  are  carefully  united  with 
sutures.    If  the  buccal  mucous  membrane  be  divided  on  a  line  a  quarter  of 


^!'*V,.rf'*^ 


Fig.  773. — Cheiloplasty  with  the  formation  of  a  flap 
from  the  chin.    After  suture  (Langenbeck). 


Fig.  774.— Cheiloplasty 
(Syme-Buchanan). 


an  inch  or  so  posterior  to  the  division  of  the  cheek,  a  vermilion  border  may 
be  formed  by  sewing  the  membrane  to  the  integument  after  the  flaps  are 
properly  placed  and  united.  The  resulting  wounds  of  the  cheeks  are  closed 
Avith  sutures. 


PLASTIC   SURGERY. 


609 


Langenbeck's  Method. — Langenbeck  devised  this  method  to  meet  those 
cases  in  which  the  tissues  of  the  chin  only  are  available  for  use  (Fig.  773). 
The  flap  may  be  made  single  or  double,  according  to  the  demands  of  the 
case.  In  the  single-flap  method  the  oblique  margin  of  the  defect  is  made 
to  correspond  to  the  proximate  part  of  the  new  lip.  The  oblique  incision 
is  then  prolonged  downward,  and  in  other  requisite  directions,  sufficiently 
to  construct  a  flap  of  suitable  dimensions  to  fill  the  gap.  It  will  be  noticed 
that  minor  disfigurement  follows  the  union  of  the  borders.  It  is  an 
obvious  fact,  however,  that  it  is  impossible  to  construct  a  complete  ver- 
milion border  in  this  instance. 

The  Syme-Buchanan  Method. — This  method  is  adapted  to  restoration 
of  the  lip  when  the  loss  of  tissue  is  sustained  mainly  by  the  central  part, 
and  at  the  lower  border.  Two  quadrilateral  flaps  are  made  at  either  side  of 
the  V-shaped  incision  employed  for  the  removal  of  the  defect,  each  cor- 
responding to  half  the  length  of  the  lip,  by  carrying  downward  at  either 
side  an  incision  continuous  with  the  border  of  the  gap  (Fig.  774).  The 
width  of  the  flaps  should  correspond  after  shrinkage  to  the  width  of  the 
lip.  The  flaps  are  loosened,  carried  upward,  and  united  at  the  median  line, 
thus  effecting  the  restoration. 

Syme's  Method. — In  Syme's  method  the  operation  is  performed  by  con- 
tinuing the  sides  of  the  V-shaped  incision  (Fig.  774)  downward  and  outward 
along  the  lower  portion  of  the  cheek  in  a  curvilinear  direction  for  about  two 
inches,  dissecting  up  the  flaps  in  the  usual  manner,  raising  them  up  to  form 
the  lip,  uniting  them  in  the  median  line,  and  allowing  the  remaining  portion 
to  heal  by  granulation.  The  mucous  membrane  should  be  stitched  to  the 
integument  to  provide  a  suitable  border.  ^-^ 

Buchanan's  method  difi^ered  from  Syme's 
in  making  the  extremities  of  the  flaps 
straight.  In  other  respects  no  radical 
difference  between  these  methods  exists. 

Buck's  Method. — Buck  first  removed 
the  morbid  growth  by  the  V-shaped  in- 
cision, and  united  the  parts  in  the  usual  a 
manner.  After  union  had  taken  place, 
the  short  lower  lip  was  overhung  by  the 
upper,  giving  to  the  patient  a  sucker- 
mouthed  appearance  (Fig.  775).  The 
steps  taken  to  relieve  this  deforn^ity  can 
best  be  described  in  Dr.  Buck's  own  lan- 
guage :  "  In  order  to  insure  precision  in 
making    the    requisite    incisions,    their 

course  should  first  lie  designated  by  pins  temporarily  inserted  erect  in  the  skin 
at  certain  points,  as  shown  by  Fig.  776.  The  letters  a  a  represent  two  pins 
inserted  at  one  finger's  breadth  below  the  under-lip  border,  one  at  either  side 
of  the  chin,  a  little  to  the  outside  of  the  angle  of  the  mouth,  and  both  equidis- 
tant from  the  median  line;  h  h  are  also  two  pins  inserted,  one  on  either  side, 
into  the  upper  lip,  at  the  margin  of  the  vermilion  border,  both  equidistant 


d 


Fig.  775. — Operation  for  contracted 
lower  lip. 


610 


OPERATIVE  SURGERY. 


from  the  median  liue  and  at  such  a  distance  apart  as  to  include  between 
them  sufficient  length  of  lip  border  with  which  to  form  a  new  upper  lip. 
The  steps  of  the  operation  are,  then,  the  following :  with  the  forefinger  of 
the  left  hand  placed  on  the  inside  of  the  mouth,  the  cheek  is  held  moderately 
on  the  stretch,  while  with  a  sharp-pointed  knife  it  is  transfixed  at  the  point 
«,  as  marked  by  the  lower  pin  in  the  side  of  the  chin.     An  incision  is  then 

carried  through  the  entire  thickness 
of  the  cheek  upward  and  a  little  out- 
ward, a  distance  of  one  inch  and  a 
half  to  a  point  c,  near  the  middle  of 
the  cheek.  The  upper  lip  should  next 
be  transfixed  at  the  point  S,  marked 
by  a  pin  on  the  vermilion  border,  and 
the  incision  carried  through  the  lip 
and  cheek  outward  and  a  little  up- 
ward to  join  the  first  incision  at  its 
terminus  c  in  the  middle  of  the  cheek. 
A  triangular  patch,  5  c  a,  will  thus  be 
formed  which  will  include  the  entire 
thickness  of  the  cheek,  with  its  apex 
free  and  disconnected  while  its  base 
remains  attached  toward  the  mouth. 
The  next  step  is  to  transfer  the  patch 
from  the  cheek  to  the  side  of  the  chin. 
For  this  purpose  an  incision  should  be 
made  on  the  side  of  the  chin  from  the 
starting-point  of  the  first  incision  a,  vertically  downward  to  the  edge  of  the 
jaw  and  to  the  depth  of  the  periosteum.  The  edges  of  this  incision,  retracting 
wide  apart,  afford  a  V-shaped  space  for  the  lodgment  of  the  triangular  patch, 
which  is  now  to  be  brought  around  edgewise  and  adjusted  by  sutures  in 
the  new  location.  By  this  transfer,  the  portion  of  the  upper-lip  border  that 
formed  a  part  of  the  base  of  the  patch  is  brought  into  a  transverse  line  con- 
tinuous with  the  lower  lip,  and  forms  an  extension  of  it.  The  space  upon 
the  cheek,  from  which  the  triangular  patch  was  taken,  is  closed  by  bringing 
its  edges  together  and  securing  them  by  sutures.  By  this  adjustment  a  new 
and  naturally  shaped  angle  is  formed  for  the  mouth  at  the  point  h,  where 
the  lip  was  transfixed  in  commencing  the  second  incision  of  the  cheek. 
The  incisions  must  be  made  with  the  utmost  precision,  and  special  care 
taken  that  the  mucous  membrane  is  divided  exactly  to  the  same  extent  as 
the  skin.  The  same  procedure  may  be  applied  to  the  other  side  of  the  mouth 
and  executed  at  the  same  operation." 

Malgaigne's  Method  (Fig.  777). — In  Malgaigne's  method  the  growth  is 
removed  by  means  of  one  horizontal  and  two  vertical  incisions.  The  vertical 
incisions  begin  at  the  angles  of  the  mouth,  the  horizontal  one  is  located  be- 
tween the  angles  and  below  the  disease.  Two  additional  horizontal  incisions 
are  subsequently  made  on  each  side  to  permit  the  closure  of  the  gap  by  the 
sliding  method.     The  flaps  are  freely  separated,  brought  forward,  united  in 


Fig.  776. — Buck's  incision. 


PLASTIC  SURGERY. 


fill 


the  median  line,  and  the  mucous  membrane  of  their  upper  borders  is  stitched 
to  the  integument.  The  mucous  membrane  can  in  this  instance  be  taken 
with  the  cheek  flap  to  form  the  vermilion  border,  as  in  Celsus's  method. 


Fig.  777. — Malgaiojne's  method. 


Sedillot's  Method'  (Fig.  778). — The  diseased  portion  is  removed  as  in 
the  preceding  method,  after  which  the  vertical  incisions  are  extended  to  the 
lower  border  of  the  jaw,  then  backward  far  enough  to  make  flaps  of  sufiicient 


Fig.  778.— Sedillot's  method. 

width  to  fill  the  gap ;  thence  directly  upward  to  a  point  opposite  the  angle 
of  the  mouth.  These  flaps  are  dissected  up  and  united  in  the  median  line 
by  the  usual  means. 

Dowd's  Method. — This  method  exposes  the  sub- 
maxillary spaces  for  removal,  of  diseased  lymph 
nodes,  also  affords  better  adjustment  of  the  flaps 
than  does  the  preceding  method. 

The  Operation. — Eemove  the  primary  growth 
as  indicated  (Fig.  779)  half  to  three  fourths  of  an 
inch  from  its  margin;  make  then  two  deep  diverg- 
ing incisions,  one  at  either  side,  and  located  so  as 
to  permit  of  exposition  of  the  submaxillary  con- 
tents; make  two  horizontal  incisions,  one  at  either 
side,  each  beginning  at  the  angle  of  the  mouth  and 
extending  liackward  two  inches  or  more,  as  may  be 
required,  down  to  the  buccal  mucous  membrane; 
expose  upward  from  these  incisions  for  a  third  of  an  inch  the  mucous 
membrane,  dividing  it  at  this  the  upper  limit  from  before  backward  at  either 
side,  sufficiently  to  constitute  ample  tissue  for  a  complete  vermilion  border' 
of  the  new  lip;  remove  carefully  from  each  submaxillary  space  the  lymph 


Fig.  779.— Dowd's  method. 


612 


OPERATIVE   SURGERY. 


Fig.  780.— Buck's  method. 
Interolateral  flap. 


nodes  whether  enlarged  or  not ;  liberate,  approximate  and  unite  the  flaps  in 
the  median  line,  without  undue  tension;  stitch  the  flap  of  mucous  mem- 
brane to  the  tegumentary  border  of  the  new  lip,  thus  forming  the  vermilion 
covering;  take  away  at  each  angle  of  the  mouth  the  integumentary  redun- 
dancy, by  removing  triangular  wedges  of  skin,  as  shown  in  the  illustration, 

closing  the  gaps  with  sutures;  dress  the 
wound  lightly,  and  keep  the  dressing  clean. 
The  Remarks. — As  much  undisturbed 
tissue  as  possible  should  be  left  on  the 
prominence  of  the  chin.  The  facial  ves- 
sels are  usually  severed  by  the  submax- 
illary incisions.  The  submaxillary  salivary 
glands  are  seldom  cancerous,  except  from 
contact  with  contiguous  infected  nodes. 

Deformities  of  the  Upper  Lip.— If  the 
deformity  here  be  slight,  it  can  be  remedied 
by  the  simple  means  employed  upon  the 
lower  lip. 

Buch's  Method — I niero -lateral  Flap. — 
Buck  practiced  this  method  to  restore  one 
half  of  the  upper  lip  and  the  adjacent  por- 
tion of  the  cheek  (Fig.  780).  He  divided  the  under  lip,  where  it  joins  the 
cheek,  by  a  vertical  incision,  a  h,  one  inch  in  length,  at  right  angles  to  its 
border.  He  made  a  second  incision,  h  c,  one 
inch  and  a  half  in  length,  beginning  at  the 
lower  end  of  the  first,  a  h,  and  running  for- 
ward parallel  with  the  border  of  the  lower 
lip.  An  oblique  incision,  c  d,  about  half  an 
inch  in  length,  was  then  made  uj)ward  and 
forward  from  the  end  of  the  horizontal  one, 
leaving  the  flap  with  a  good  attachment  at  the 
point  of  finishing.  He  pared  the  edges  of  the 
deformity  and  the  adjoining  end  of  the  half  lip 
above,  and  separated  the  latter  from  its  bony 
attachments  by  free  section  of  the  underlying 
tissues  directed  upward  toward  the  orbit.  The 
under-lip  flap  was  then  tipped  endwise,  and  its 
upper  extremity  connected  by  sutures  with  the 
freshened  end  of  the  half  upper  lip.  The  re- 
maining space  between  the  flap  and  cheek  was 
closed  by  sutures. 

Bruns,  in  order  to  utilize  the  healthy  por- 
tion of  the  mucous  membrane,  reflected  from 
the  inner  surface  of  a  diseased  lower  lip  in  making  a  vermilion  border 
for  the  newly  constructed  labrum,  circumscribed  the  morbid  growth 
(Fig.  780  a)  by  carrying  inward  beneath  and  below  it  from  the  angle 
of  the  mouth  an  incision  which,  meeting  another  including  the  lip  at 


Fig.  780  «.— Bruns's  method. 
Vermilion  border  plan. 


Fig.  780  6.— Bruns's  method. 
Vermilion  border  made. 


PLASTIC  SURGERY. 


613 


the  opposite  side,  passed  downward  and  outward  beneath  the  jaw  in  a 
manner  permitting  of  the  examination  and  removal  of  the  sul)ina\illary 
lymph  nodes  (Fig.  780  a).  The  removal  of  the  growth,  the  sliding  up  into 
place  of  the  flap  and  the  covering  of  the  new  upper  border  with  the  rem- 
nant of  mucous  membrane  belonging  to  the  inner  surface  of  the  lip,  is  shown 
in  Fig.  780  b.  The  submaxillary  glands  of  the  opposite  side  should  not  escape 
attention. 

Entire  Loss  of  the  Upper  Lip. — This  deformity  may  be  repaired  by  semi- 
circular vertical  flaps  or  by  the  lateral-flap  method. 

Buch's  Semicircular  Vertical-flap  Method  (Fig.  781). — Commence  an 
incision  at  the  median  line  on  a  level  with  the  floor  of  the  nasal  cavity; 
carry  it  outward  and  downward 
in  a  semicircular  direction  around 
one  side  of  the  mouth  to  a  point 
below  the  lower  lip  corresponding 
to  the  junction  of  its  outer  and 
middle  thirds,  a  h ;  make  a  similar 
incision,  a  c,  around  the  other  side 
of  the  mouth.  These  incisions  are 
carried  through  the  entire  thick- 
ness of  the  cheeks  and  lips  at  a  d— 
uniform  distance  of  an  inch  and 
a  quarter  from  the  border  of  the 
opening.  Dissect  the  remaining 
portions  of  the  cheeks  freely  from 
their  attachments  beneath,  that 
they  may  be  easily  brought  forward. 
The  upper  extremities  of  the  semi- 
circular flaps  are  trimmed  off  at  a  proper  angle,  e  d,  after  which  they  are 
united  in  the  median  line  by  the  usual  means.  The  interval  between  the 
cheeks  and  the  newly  constructed  mouth  is  closed  by  sutures. 


a 


a 


e- 


c 


Fig.  781. — Semicircular-flap  method. 


Fig.  782. — Sedillot's  vertical-flap  method. 


Sedillot's  Vertical-flap  Method  (Fig.  782).— The  bases  oi  the  flaps  in  this 
method  may  be  made  either  upward  or  downward,  the  former  being  the 
better  plan.  They  should  comprise  the  entire  thickness  of  the  cheeks, 
their  length  and  width  corresponding  to  the  dimensions  of  the  proposed 
new  lip,  plus  an  allowance  of  one  fourth  for  shrinkage.     They  are  carried 


614 


OPERATIVE  SURGERY. 


into  position  and  united  in  the  median  line.  The  gaps  in  the  cheek  may 
be  closed  by  sutures  or  allowed  to  heal  by  granulation. 

Dieffenbach's  S-shaped-flap  Method. — Freshen  the  lower  border  of  the 
remaining  portion  of  the  original  lip,  then  raise  two  S-shaped  flaps,  one  at 
each  side  of  the  nose,  extending  down  to  the  angle  of  the  mouth,  turn  them 
across  the  space  in  front  of  the  alveolar  process,  unite  them  to  each  other 
and  also  to  the  freshened  border  beneath  the  nose  (Fig.  783). 

Dieffenhaclis  Curved-fla'p  Method  (Fig.  752). — This  method  of  Dieffen- 
bach  is  employed  where  the  central  part  of  the  lip  is  gone  and  the  gap 


Fig.  783. — Dieffenbach's  S-shaped  method. 

is  covered  with  mucous  membrane.  Two  flaps  are  formed  by  curved  in- 
cisions, each  beginning  at  the  apex  of  the  defect  and  carried  one  at  either 
side  of  the  alse  of  the  nose.  The  mucous  membrane  of  the  gap  is  partially 
detached  from  above  and  turned  downward.  The  flaps  are  liberated,  brought 
together  in  the  median  line,  united,  and  so  joined  with  the  reflected  mu- 
cous membrane  as  to  provide  for  the  new  lip  a  vermilion  border. 

Szymanowski's  Method. — In  this  method  a  lateral  flap  the  width  of 
the  lip  is  cut  from  the  cheek  at  either  side  (Fig.  784).    The  outer  extrem- 


PiG.  784. — Szymanowski's  method. 

ities  are  curved  downward  so  as  to  lessen  the  tension.  The  flaps  are  liber- 
ated the  entire  length,  brought  forward  into  position,  and  united  at  the 
median  line.  If  the  buccal  mucous  membrane  be  divided  a  quarter  of  an 
inch  below  the  inferior  incisions  in  the  cheeks,  it  can  be  utilized  for  the 
formation  of  a  vermilion  border  after  the  flaps  are  properly  united. 


PLASTIC  SURGERY. 


615 


Ledran-Mackenzlc  Method  (Fig.  785). — The  ingenious  method  of  repair 
of  the  loss  of  a  large  portion  of  the  lips  of  one  side  and  of  the  corresponding 
cheek  by  flaps  taken  from  the  chin  and  neck,  and  united  to  the  extremities 
of  the  upper  {p!  to  a)  and  tlie  lower  ih'  to  h)  lips  respectively,  is  easily  com- 


FiG.  785.— Ledran- 
Mackenzie  method. 


Fig.  786. — Repair  of  chin,  cheek,  and  lips.    (Vanzette.) 


prehended.  Another  and  quite  complicated  method  of  practice  for  repair 
of  the  chin,  cheek,  and  lips  is  presented  (Fig.  786).  This  demonstrates  the 
cosmetic  result  that  may  be  attained  when  the  use  of  highly  vitalized  tissues 
is  supplemented  by  ingenious  surgical  planning. 

Stomatoplasty.— The  operation  of  stomatoplasty  is  employed  to  increase 
the  size  of  a  narrowed  mouth,  or  to  regulate  a  mouth  that  is  abnormally 
shaped,  from  deformities  either  incident  to  disease  or  resulting  from  pre- 
vious operative  procedure. 

The  deformity  can  be  corrected  by  an  operation  already  described  when 
the  lower  lip  is  the  contracted  portion.  In  any  instance  the  angles  of  the 
new  mouth  may  be  formed  by  means  of  transverse  incisions  made  at  the 
proper  situations.  Whenever  these  incisions 
are  made  the  mucous  membrane  must  be 
stitched  over  the  raw  surfaces  to  prevent 
them  from  becoming  united. 

Buck's  Method. — The  method  described 
by  Buck  for  restoring  the  angles  of  the  mouth 
is  simple  and  effective  (Fig.  787).  A  curved 
incision  is  made  with  great  exactness  along 
the  line  of  the  vermilion  border,  circumscrib- 
ing one  lateral  half  of  the  mouth,  and  extend- 
ing to  an  equal  distance  along  the  upper  and 
lower  lips,  a  to  h.  This  incision  should  only 
divide  the  skin  and  not  involve  the  mucous 
membrane.  A  sharp-pointed,  double-edged 
knife  is  inserted  at  the  middle  of  this  curved 
incision,  and  directed  toward  the  cheek,  flat- 
wise, between  the  skin  and  mucous  membrane,  so  as  to  separate  them  from 
each  other  as  far  outward  as  the  new  angle  of  the  mouth  is  required  to 
be  placed. 

The  skin  alone  is  next  divided  outward  on  a  line  with  the  commissure  of 
the  mouth,  d  to  r.     The  underlying  mucous  membrane  is  then  divided  in 


Fig.  787. — Stomatoplasty. 


616 


OPERATIVE  SURGERY. 


the  same  line,  but  not  so  far  outward.  The  angles  at  the  outer  ends  of 
these  two  latter  incisions  are  accurately  united  by  a  single-thread  or  fine  silk- 
worm-gut suture.  The  freshly  cut  edges  of  skin  and  mucous  membrane, 
above  and  below,  that  are  to  form  the  new  lip  borders,  are  to  be  shaped  by 
paring  first  the  skin  and  then  the  mucous  membrane  in  such  a  manner 
that  the  latter  shall  overlap  the  former  after  they  have  been  secured  together 
by  fine  sutures  at  short  intervals. 

Serre's  Method. — Serre's  method  is  practiced  for  the  restoration  of  the 
angle  of  the  mouth  (Fig.  788).  Three  incisions  are  made,  a  superior, 
external,  and  inferior.  The  first  is  placed  horizontally  in  a  line  with  the 
upper  border  of  the  mouth;  the  second,  beginning  at  the  outer  extremity 


Fig.  788.— Serre's  method. 


of  the  first,  passes  downward  and  inward  near  to  the  angle  of  the  de- 
formity, and  then  directly  downward  for  a  short  distance;  the  third 
passes  from  tlie  border  of  the  lower  lip  just  within  the  deformity,  down- 
ward and  outward  to  join  the  lower  end  of  the  second,  thus  forming  a 
smaller  triangle  below  with  its  base  opposed  to  that  of  a  larger  one 
above.  The  circumscribed  tissues  are  removed,  the  bases  of  the  triangles 
caused  to  meet  at  the  angle  of  the  mouth,  and  the  borders  are  joined 
with  sutures. 

Meloplasty. — Meloplasty  relates  to  the  restoration  of  defects  of  the  cheek 
dependent  on  cicatricial  changes  caused  by  noma,  etc.     The  rules  of  action 
in  this  operation  are  substantially  similar  to  those  employed  in  plastic  re- 
pairs of  other  parts.    The  utilization 
of  skin  from  the  neck  and  of  that 
adjacent  to  the  eyelids  and  the  lips 
for  flaps  is  objectionable,  because  of 
the  disfigurement  incident  to  con- 
traction, and  when  thus  employed 
the  probable  need  of  a  supplement- 
ary procedure  should  be  well  under- 
stood.    In  the  instance  of  locked 
jaw  from  cicatricial  tissue,  the  tis-. 
sue  must  be  dissected  away  freely 
Fig.  m.—a  Meloplasty  by  the  use  of  two   ^nd    sound    structures    alone    em- 
pedunculated    Haps  irom   the   cheek  and       -,         -,    ■  •  m         ^  j.i 

chin.     &.  Condition  after  suture.  ployed   m   repair.      Iwo    flaps,    the 

upper  taken  from  the  cheek  and 
the  lower  from  the  cheek,  neck,  and  chin,  are  employed  sometimes  to  cure 
a  crippling -defect  (Fig.  789). 


PLASTIC  SURGERY. 


en 


Gussenhauers  Method. — This  method  is  commended  for  those  cases  of 
lodged  jaw  dependent  on  contraction  caused  by  extensive  ulcerations  and 
sloughing  of  the  mucous  membrane  of  the  cheeks.  It  is  of  no  avail,  how- 
ever, in  those  cases  in  which  the  integumentary  structures  of  the  cheek 
are  involved. 

The  Operation. — Fashion  from  the  cheek  and  reflect  backward  to  the 
anterior  border  of  the  masseter  a  skin  flap  about  an  inch  and  a  quarter 
broad  in  front  and  two  inches  and  a  half 
broad  behind;  remove  the  subcutaneous  soft 
parts  of  the  cheek  and  the  scars  back  to  the 
anterior  border  of  the  masseter;  so  turn  into 
the  defect  the  superficial  flap  that  its  anterior 
border  and  the  sides  can  be  united  with  those 
of  the  divided  mucous  membrane  lying  beneath 
and  in  front  of  the  masseter,  thus  bringing  the 
epithelial  surface  innermost;  divide  the  pedi- 
cle of  the  flap  at  the  end  of  the  fourth  week 
and  turn  the  superficial  part  of  the  fiap  for- 
ward; unite  it  to  the  borders  of  the  remaining 
part  of  the  defect,  thus  closing  the  defect  en- 
tirely; cover  the  outer  surface  of  the  flap  with 
a  rectangular-shaped  one  slid  into  place  from  the  lower  jaw  (Fig.  790). 

Trendelenhurg  advises  the  application  of  one  or  two  flaps,  as  the  case 
may  be,  taken  from  the  cheek,  temple,  lower  jaw,  or  chin,  to  defects  due  to 
removal  of  cicatricial  tissue  involving  the  entire  structure  of  the  cheek. 
The  cuticular  surfaces  are  turned  innermost,  and  the  outer  or  raw  surface 
is  skin-grafted,  or  instead  covered  with  an  independent  flap  slid  into  place 
from  a  contiguous  surface. 

Israel  closed  a  defect  of  the  skin  and  mucous  membrane  of  the  cheeks 
by  means  of  a  single  long  flap  raised  from  the  side  of  the  neck  and  supra- 


FiG.  790. — Restoration  of  the 
cheek  and  mouth.  (Gussen- 
baner.) 


Fig.  791.— Meloplasty.     (Israel.) 

scapular  region  down  to  the  clavicle,  with  the  pedicle  just  below  the  angle 
of  the  jaw  (Fig.  791).  The  flap  was  turned  into  the  defect  and  sutured  in 
place  and  the  wound  closed.  After  seventeen  days  the  pedicle  was  divided 
and  the  raw  surface  of  the  posterior  portion  was  applied  to  that  of  the  ante- 
rior by  doubling  the  flap,  thus  providing  a  cuticular  outer  surface  to  the 
41 


618 


OPERATIVE  SURGERY. 


cheek.  The  remaining  border  of  the  flap  and  those  of  the  defect  were 
closely  adjusted  with  sutures  and  an  extended  mucous  border  provided  from 
the  mucous  membrane  of  the  lips.  Haiin  closed  a  like  defect  in  a  similar 
manner  by  a  long  flap  taken  from  the  chest.  Czerny  raised  a  very  long 
large  flap  from  the  cheek  and  neck  with  the  pedicle  corresponding  to  the 
zygoma.  The  flap  included  the  platysma  and  was  carried  upward  and  so 
folded  on  itself  as  to  permit  the  ajsex  to  be  sutured  to  the  posterior  part  of 
the  defect,  with  the  cuticular  surface  innermost.  The  borders  of  the  flap 
were  united  to  those  of  the  defect  and  the  wound  closed  with  sutures. 
Later  the  pedicle  was  divided  and  the  operation  completed. 

Gersuny  used  a  flap  for  a  similar  purpose  having  a  pedicle  of  subcu- 
taneous tissue  only.  Flaps  with  these  pedicles  are  admirable  and  can  be 
turned  directly  into  place  or  indirectly  through  a  slit  made  in  the  skin. 


vV  ^^ 


^<^ 


Fig.  793.— Meloplasty.    (Kraske.)  Pig.  793.— Lalleinand's  method, 

without  inversion  of  the  flap, 

Kraske  closed  a  defect  in  the  cheek  by  a  flap  taken  from  the  immediate 
locality  (Pig.  792).  The  flap  was  turned  over  and  stitched  in  place  with 
the  integumentary  surface  innermost,  and  the  raw  surfaces  covered  at  once 
with  Thiersch's  skin  grafts. 

Lallemdnd  carried  a  flap  from  the  neck  into  a  defect  of  the  cheek  and 
lips  resulting  from  removal  of  a  neoplasm,  joining  a'  to  a,  V  to  I,  c'  to  c, 
therefrom  without  inversion  of  the  cuticular  surface  (Fig.  793).  However, 
inversion  with  prompt  grafting  of  the  raw  surface  is  the  better  when 
practicable. 

The  Eemarhs. — In  those  cases  in  which  plastic  measures  afford  no  relief, 
either  extraction  of  the  teeth,  excision  of  the  jaw  from  the  corner  of  the 
mouth  to  the  articulation,  and  possibly  excision  of  the  zygoma,  may  be 
required. 

Operations  upon  the  Palate.— The  operations  employed  to  relieve  the 
deformities  of  the  hard  and  soft  palate  are  denominated  staphylorrhaphy, 
uranoplasty  and  staphyloplasty  (Fig.  794).     The  armamentarium  usually 


PLASTIC  SURGERY. 


619 


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620 


OPERATIVE  SURGERY. 


assigned  to  these  operations  is  quite  elaborate,  and  in  many  respects  need- 
less. Ordinary  tenotomes  and  knives  meet  the  indications  quite  well  indeed. 
Staphylorrhaphy. — Staphylorrhaphy  consists  in  closing  an  abnormal 
opening  in  the  soft  palate  by  bringing  its  freshened  borders  in  contact 
with  each  other.  These  openings  vary  in  extent  from  a  simple  cleft  of  the 
uvula  to  a  complete  fissure  of  all  the  soft  parts  (Fig.  795). 


Fig.  795. — Degrees  of  deformity. 

The  Comments. — The  length  of  the  cleft  is  of  less  significance  than  the 
width,  as  narrow  clefts  are  more  easily  closed  than  wide  ones.  However, 
the  condition  of  the  tissues  of  the  soft  palate  is  of  importance  in  either  case, 
for  if  they  be  contracted  or  atrophied  the  difficulties  are  increased,  espe- 
cially in  connection  with  the  wider  clefts.  Spoiled  children,  and  those  with 
bad  tempers  and  of  indifl'erent  health,  are  ill  suited  for  the  operation.  Ac- 
cording to  Mr.  Thomas  Smith,  simple  clefts  of  the  velum  may  be  closed  at  the 
third  year  of  life  in  proper  cases.  If  a  limited  involvement  of  the  hard  pal- 
ate be  present,  the  operation  should 
be  deferred  for  three  or  four  years 
longer.  The  simultaneous  closure  of 
both  hard  and  soft  parts  is  regarded 
as  the  better  practice.  While  strong 
solutions  of  cocaine  may  be  sufficient- 
ly potent  for  closure  of  short,  narrow 
fissures,  without  pain,  in  older  chil- 
dren or  adults,  still,  except  perhaps 
in  the  simplest  cases,  it  is  wiser  to 
employ  an  anaesthetic  in  all  sensitive 
patients.  Horsehair  sutures  for  re- 
laxed tissues,  and  silkworm  gut  and 
fine  silver  wire  for  tense  ones,  are 
sufficient.  The  position  of  the  pa- 
tient during  operation  is  a  matter 
for  the  comfort  and  expediency  of 
Pig.  796.— Rose's  position.  the  operator,  and  often  of  safety  to 

the  patient.  The  patient  should  be 
placed  on  a  narrow  table  of  suitable  height,  with  the  head  raised  and  thrown 
back.  Ease  advises  that  the  head  be  thrown  far  backward  (Fig.  796),  so  that 
the  blood  will  collect  in  the  upper  part  of  the  pharynx  rather  than  enter  the 


PLASTIC  SURGERY. 


621 


trachea.  Inasmuch  as  in  this  position  the  manipulations  of  the  surgeon  are 
hindered,  and  the  cranial  circulation  of  the  patient  is  somewhat  ohstructed, 
a  reasonable  doubt  as  to  the  wisdom  of  the  posture  can  be  entertained.  Some 
time  prior  to  the  operation,  the  patient  should  be  instructed  by  manipida- 
tion  to  control  properly  the  fauces,  so  that  the  surgeon  may  handle  the  parts 
without  causing  involuntary  movements  of  them. 

If  the  cleft  extends  through  the  whole  of  the  soft  palate,  or  even  en- 
croaches somewhat  upon  the  hard  portion,  it  may  be  necessary,  especially  if 
the  gap  be  wide  and  the  muscles  controlling  it  be  active,  to  overcome  the 
muscular  influence  before  attempting  to  unite  the  cleft.  The  tensor-  and 
levator-palati  muscles,  together  with  the  palato-glossi  and  palato-pharyngei, 
are  the  ones  that  exercise  contractile  influence  on  the  part,  and  if  they  be 
properly  severed  the  velum  Mill  remain  motionless  and  flaccid.  The  accom- 
panying illustration  shovvs  their 
relations  to  the  important  con- 
tiguous tissues  (Fig.   797). 

The  palato-pharyngei  muscles 
can  be  cut  with  a  pair  of  blunt- 
pointed  scissors,  by  dividing  the 
posterior  pillars  of  the  fauces,  of 
which  they  form  the  principal 
part.  The  palato-glossi  muscles, 
comprising  the  anterior  pillars, 
may  be  cut  in  a  similar  manner. 
The  remaining  muscles,  after  first 
passing  a  silken  thread  through 
the  velum  on  each  side  of  the 
cleft  at  points  corresponding  to 
the  origin  of  the  uvula,  loo^Ding 
the  extremities  of  the  threads  and 
making  the  velum  tense  with  a  te- 
naculum (Fig.  794,  h),  are  divided. 

The  Tensor  Palati. — Eecognize 
the  hamular  process  around  which 
the  tendon  of  the  tensor  palati  runs 
to  the  upper  posterior  molar  tooth. 


FiCt.  797.— Muscles  of  Uie 
of  division  of  muscles, 
c.  Palatine  vessels. 


iolt  palate,     a.  Line 
b.  Line  of  incision. 


it  is  located  a  little  behind  and  internal 
Make  tense  that  segment  of  the  velum  by 
the  traction  suture  just  introduced,  and  enter  the  point  of  a  narrow-bladed 
knife  (Fig.  794,  a  and  h)  a  little  below  and  at  the  inner  side  of  the  process 
with  the  edge  upward ;  carry  it  upward,  backward,  and  inward,  until  the  point 
is  seen  through  the  gap ;  this  divides  almost  the  entire  width  of  the  velum, 
with  the  main,  if  not  the  entire,  portion  of  the  tendon  of  the  tensor  palati. 

The  Levator  Palati. — Many  of  the  lowermost  fibers  of  this  muscle  will  be 
cut  in  the  division  of  the  preceding  one.  If  a  greater  section  be  required, 
depress  the  handle  of  the  knife  and  carry  it  outward,  so  as  to  make  an 
oblique  incision  on  the  posterior  surface  of  the  velum  as  it  is  withdrawn. 

The  Remarls. — It  is  well  to  allow  two  or  three  days  to  elapse  after 
division  of  the  muscles  before  attempting  the  union  of  the  cleft,  so  as  to 


622 


OPERATIVE  SURGERY. 


permit  hajmorrhage  and  inflammatory  action  to  subside,  and  to  determine 
more  clearly  whether  further  section  will  be  required.  The  levator  muscle, 
if  it  be  made  tense  by  drawing  the  velum  toward  the  incisor  teeth  by  means 
of  the  silken  thread,  may  be  cut  with  blunt  scissors  under  direct  observation, 
especially  if  the  cleft  be  deep. 

The  Operation  of  Staphylorrhaphy. — There  are  three  steps  to  the  opera- 
tion of  staphylorrhaphy :  1.  Freshening  the  edges  of  the  cleft.  2.  Passing 
the  sutures.  3.  Coaptating  the  divided  borders  and  tying  the  sutures. 
First  apply  a  solution  of  cocaine  to  the  palate,  if  advisable,  and  then, 
placing  the  patient  in  a  chair  or  on  a  table  which  will  permit  the  head  to  be 
thrown  well  back  so  as  to  expose  the  parts  to  a  strong  light,  insert  the  gag 
and  draw  the  cheeks  aside  (Fig.  798).  The  lower  point  of  one  border  of  the 
cleft  is  then  seized  with  the  forceps,  made  tense,  and  the  border  freshened 
from  below  upward  (Fig.  799),  or  the 
reverse  if  desired.  Treat  the  opposite 
side  in  a  similar  manner. 


Fig.  799. 


Fig.  798. 

Fig.  798. — Whitehead's  mouth  gag. 
Pig.  799. — Freshening  the  borders  of  the  cleft.     Cheeks  drawn  aside  by  elastic  traction. 
Sutures  supported  by  hooks  on  band  around  head. 


If  an  ansesthetic  has  not  been  employed,  the  patient  is  allowed  to  rest 
after  the  completion  of  the  first  step,  until  the  hgemorrhage  ceases  and  self- 
control  is  regained.  The  sutures  should  be  half  a  yard  in  length,  doubled 
before  passing,  and  thoroughly  aseptic.  Either  horsehair,  silkworm-gut,  or 
metallic  sutures  can  be  employed.  Three  or  four  are  usually  sufficient. 
The  first  should  be  introduced  at  the  middle,  the  second  at  the  lower  ex- 
tremity, of  the  gap,  while  the  remaining  ones  close  the  spaces  between.  They 
can  be  passed  from  before  backward  on  one  side,  and  from  behind  forward 
on  the  other,  by  means  of  the  needle  holder  and  the  ordinary  short-curved 
needle  (Fig.  800),  or  in  the  following  manner  by  means  of  a  curved  needle 
with  the  eye  near  the  point  (Fig.  79-1,  c).  Seize  the  left  side  of  the  cleft 
with  forceps,  and  carry  the  needle  through  it  at  the  point  selected,  from 


PLASTIC  SURGERY. 


623 


before  backward ;  draw  one  end  of  the  suture  through  between  the  borders 
of  the  cleft;  withdraw  the  needle,  arm  it  with  another  suture,  and  pass  it 
on  the  opposite  side  in  the  same  manner;  catch  the  thread 
and  withdraw  the  needle,  leaving  the  looped  suture  in  the 
border  of  the  cleft  (Fig.  bOl) ;  then  pass  the  end  of  the 
ligature  first  inserted  through  the  loop,  which  is  forthwith 
drawn  out,  carrying  the  single  thread  through  the  right  side. 
The  remaining  sutures  are  passed  in  a  similar  manner. 
Each  one  is  tied  somewhat  loosely,  to  allow  for  the  swelling, 
with  a  reef  knot,  or,  what  is  better,  the  slip  knot  held  in 
place  by  a  second  knot  tied  over  it.  The  suture  last  passed 
should  be  always  left  uncut  so  that  the  borders  can  be 
steadied  by  traction  upon  it  during  the  passage  of  the  next 
succeeding  one.  Perforated  shot  may  be  passed  over  the 
sutures  and  held  in  position  by  compressing  them,  or  by  the 
ordinary  knot.  If  silver  wire  be  used,  it  must  be  very  fine 
and  flexible,  and  applied  with  an  adjuster.  The  sponging 
during  the  operation  must  not  be  done  with  any  form  of 
antiseptic  fluid  of  a  poisonous  nature,  since  the  patient  may 
swallow  a  certain  portion  of  it  with  an  objectionable  result, 
and,  too,  sponging  should  be  done  sparingly,  as  it  excites 
movements  of  the  parts  and  hinders  operation.  The  sutures 
are  left  sufficiently  long  to  admit  of  their  easy  removal,  which 
is  done  at  the  end  of  a  week.  The  diet  should  be  plain,  and 
all  conversation  interdicted. 
Fig.  800.— Gross's  -^^^^  Results. — The  prospect  of  union  of  the  parts  is  very 
needle  forceps,  favorable,  scarcely  more  than  five  per  cent  of  the  operations 
being  failures.  The  time  necessary  to  acquire  a  distinct  voice 
is  variable,  and  often  this  is  not  attainable.  The  death  rate  in  cleft-palate 
operations  before  the  fourth  month  is  about  fifty  per  cent.  The  unfavorable 
condition  of  the  patient  adds  much  to  this  result. 

Uranoplasty. — Uranoplasty  is  performed  to  close 
a  fissure  in  the  hard  palate.  It  is  divided  into  two 
stages :  1,  the  formation  of  the  flaps ;  2,  the  ar- 
rest of  haemorrhage  and  the  adjustment  and  uniting 
of  the  flaps. 

The  patient  is  anaesthetized,  and  so  placed  in  a 
chair  or  on  a  table  as  to  permit  of  a  good  light,  and 
the  gag  is  introduced. 

Langenheck's  Method — the  First  Step. — If  there 
be  sufficient  tissue,  pare  the  mucous  edges  of  the 

cleft,  otherwise  omit  the  paring  and  proceed  at  once  to  raise  the  muco- 
periosteal  flaps  from  the  bone.  This  is  done  by  first  making  an  incision 
down  upon  the  bone  (Fig.  802)  with  a  scalpel  atthe  margin  of  the  alveolar 
border  of  sufficient  length  to  admit  a  slightly  curved  elevator  (Fig.  794,  d). 
The  instrument  is  thrust  through  the  incision  inward  on  the  bone  to  the 
cleft,  causing  a  limited  separation  of  the  muco-periosteal  flap  at  that  situa- 


801. — Looped  suture 
and  slip  knot. 


624 


OPERATIVE  SURGERY. 


tion.  It  is  then  withdrawn  and  another  with  a  greater  curve  is  inserted  into 
the  opening  at  the  border,  and  with  this  the  flap  is  separated  from  the  bone 
by  to-and-fro  movements  the  entire  length  of  the 
cleft.  The  soft  palate  is  drawn  forward  and  its 
connection  with  the  bone  divided  the  entire  width  of 
the  flap  with  scissors.  Eepeat  the  operation  on  the 
opposite  side.  Arrest  haemorrhage  and  renew  the  an- 
gesthetic  preparatory  to  the  next  step  of  the  operation. 
The  Second  Step. — Freshen  the  adjoining  bor- 
ders of  the  flaps  and  unite  them  with  fine  silver- wire 
or  silkworm-gut  sutures.  If  tension  of  the  flaps  be 
noted,  the  external  incisions  for  primary  introduction 
of  the  elevator  should  be  extended  backward  even 
into  the  tissue  of  the  soft  palate  itself,  to  secure 
easy  adjustment  of  the  borders  of  the  flaps.  The 
separation  of  the  flaps  can,  however,  be  made  by  an 
extension  of  the  primary  incisions  at  the  outset,  in- 
stead of  as  before  described  (Fig.  802).  Haemorrhage 
is  more  easily  controlled  and  the  blood  directed  away 
Fig.   802.— Langenbeek's   from  the  fissure  by  the  latter  plan. 

Flaps  raised,  y/^g  Comments. — If  the  fissure  be  very  broad  and 
one  that  can  not  be  covered  with  the  flaps  already  de- 
scribed, then  flaps  are  made  by  beginning  the  incision  at  the  posterior  border 
of  the  last  molar  tooth,  or,  practically,  in  front  of  the  hamular  process,  and 
carrying  it  through  the  periosteum,  forward  along  the  inner  margin  of  the 
alveolar  process  to  the  interval  between  the  lateral  and  middle  incisors  (Figs. 
803,797,&).  If  the  curvilinear  incision  were  made  along  the  base  of  the  alve- 
olar process,  or  were  carried  forward  to  the  central  incisors,  the  posterior  and 


method. 

adjusted,  and  united. 


Fig.  803. — Curvilinear  incision  and 
cleft  with  borders  freshened. 


Fig.  804.- 


-Borders  of  cleft 
united. 


anterior  palatine  vessels  would  be  divided.  These  flaps  are  now  to  be  carefully 
detached  by  a  periosteotome,  from  without  inward  and  from  before  backAvard 
until  the  edges  of  the  fissure  are  reached ;  they  are  then  carried  toward  the 
median  line,  and,  if  no  degree  of  traction  be  noticed,  united  throughout  to 
each  other  by  silkworm-gut  or  silver- wire  sutures  (Fig.  804).    The  displaced 


PLASTIC  SURGERY. 


625 


Pig.  805. — Dieffenbach-Fergusson  method,  a.  Incision 
over  hard  palate,  h.  Punctures  for  chisel,  c.  Suture 
holes  in  palate,  d.  Margin  of  hard  palate,  ee.  In- 
cision through  hard  palate. 


periosteum  fills  in  the  gap  and  often  develops  sufficient  bone  to  produce  an 
admirable  degree  of  firmness.  The  sutures  are  allowed  to  remain  in  posi- 
tion ten  days  or  so;  the 
patient  is  fed  on  liquid 
food ;  any  cough  is  re- 
lieved by  anodynes,  and 
the  parts  are  kept  clean. 

The  Dieffenbach-Fer- 
gusson Method  (Fig.  805). 
— Pare  the  edges  of  the 
cleft;  make  an  incision 
on  one  side  through  the 
soft  parts  down  to  the 
bone,  parallel  to  the  cleft 
and  midway  between  it 
and  the  alveolus  (a);  di- 
vide the  bone  along  the 
line  of  incision  with  a 
chisel  (e  e)  and  displace  it 
to  the  median  line  of  the  cleft ;  treat  the  opposite  side  in  a  similar  man- 
ner, bringing  the  pared  borders  of  the  soft  parts  in  contact  with  each  other 
{c)  and  uniting  them  with  sutures.  These  sutures  can  be  fortified  by  others 
passed  entirely  around  the  displaced  portions.  The  lateral  openings  are  lightly 
packed  with  antiseptic  gauze.  If  the  cleft  be  located  only  at  one  side  of  the 
vomer,  the  osteoplastic  or  muco-periosteal  fiap  is  taken  from  the  side  of  the 
defect.  In  these  instances  the  passing  of  sutures  is  greatly  hindered.  If 
several  openings  be  made  through  the  hard  palate  in  the  line  of  incision  {I) 
with  a  brad  awl,  the  use  of  the  chisel  is  facilitated. 

The  Remarks. — Differences  of  opinion  exist  among  competent  authorities 
regarding  the  wisdom  of  this  plan  of  practice,  it  being  claimed  that  hasmor- 
rhage,  sloughing,  necrosis,  and  septicsemia  are  quite  prominent  factors 
in  its  history,  especially  in  children  of  lessened  vigor. 

Mears  uses  Adams's  saw  after  drilling  an  opening  for  its  entrance,  and 
claims  less  injury  is  thus  done  to  the  bone  than  by  any  other  means.  The 
haemorrhage  is  quite  severe  during  the  separation  of  the  muco-periosteal 
flaps,  but  it  is  readily  controlled  by  pressure  and  cold.  When  the  osteo- 
plastic flaps  are  made  the  bleeding  is  usually  still  greater. 

Lannelonguis  Method. — In  unilateral  cases  Lannelongue  constructed  a 
quadrilateral-shaped  flap  proportionate  to  the  dimensions  of  the  gap  from 
the  mucous  membrane  of  the  contiguous  surface  of  the  nasal  septum.  A 
long  horizontal  and  two  short  perpendicular  incisions  outline  the  flap,  which 
is  then  detached  with  a  thin  periosteotome  and  reflected  downward,  its  base 
remaining  attached  below  to  the  septum.  The  free  border  of  this  flap  is 
then  joined  to  the  freshened  outer  border  of  the  cleft  with  sutures.  While 
this  ingenious  measure  can  be  wisely  employed  as  a  dernier  ressort,  still, 
it  may  be  also  useful  as  a  supplementary  step  in  the  other  methods  of 
closure. 


626 


OPERATIVE  SURGERY. 


The  Davies-Colley  Method. — In  this  method  a  triangular-shaped  flap 
(ab  c),  including  the  whole  of  the  soft  parts,  is  cut  from  the  wider  portion  of 
the  hard  palate  (Fig,  807).  The  apex  of  the  flap  is  located  just  behind  the 
insertion  of  the  incisor  teeth;  the  base  {a  c)  extends  from  the  border  of  the 
alveolus  of  the  last  molar  tooth  inward  and  backward  to  near  the  border  of 
the  cleft  of  the  soft  palate  close  to  its  attachment  to  the  bone.  A  somewhat 
similarly  shaped  flap  is  formed  at  the  other  side  of  the  cleft,  the  inner  border 
of  which  {d  e)  remains  continuous  with  the  soft  parts  at  the  border  of  the 
defect.  The  flap  last  formed  is  raised  from  the  bone  with  an  elevator  and 
turned  over  across  the  cleft  while  remaining  attached  at  its  inner  border  by 
a  hinge  of  muco-periosteal  tissue  {d  e).  This  flap  is  now  joined  to  the  fresh- 
ened opposite  border  of  the  defect  with  two  or  three  catgut  sutures.  The 
first  flap  {ah  c)  is  now  raised  in  a  similar  manner  and  jumped  across  to  the 


Fig. 


806. — Davies-Colley  method. 
Flaps  marked  out. 


Fig.  807. — Davies-Colley  method. 
Flaps  in  position. 


opposite  side  and  its  apex  joined  with  the  outer  margin  of  the  opposite  gap 
by  two  or  three  silver- wire  or  silkworm-gut  sutures. 

The  Remarks. — This  operation  is  much  less  severe  than  the  preceding, 
and  therefore  can  be  employed  at  an  earlier  date.  Less  hsemorrhage  attends 
it  and  the  dangers  of  necrosis  and  septicaemia  are  not  so  distinct.  The  pres- 
sure of  the  tongue  against  the  roof  of  the  mouth  is  less  harmful. 

Fergusson's  Method. — The  child  is  wrapped  in  a  sterile  sheet,  the  arms 
extended  at  the  sides,  and  an  antiseptic  towel  or  a  rubber  cap  is  placed  upon 
the  head.  The  mucous  surfaces  concerned  in  the  operation  are  cleansed 
with  alcohol  and  water.  The  mouth  gag  is  employed  and  the  head  thrown 
back. 

The  Operation. — "  1.  With  a  slender,  slightly  curved,  narrow-bladed 
knife,  cut  through  the  mucous  membrane  of  the  mouth  about  one  sixteenth 
of  an  inch  from  the  edge  of  each  segment,  and  divide  all  the  soft  structures 
to  the  mucous  membrane  on  the  nasal  aspect  of  the  palate,  but  not  through 
it  (Fig.  808). 


PLASTIC  SURGERY. 


627 


"  2.  With  a  small,  round,  fully  curved  needle,  not  larger  than  one  half 
inch  between  the  eye  and  the  point,  held  in  a  suitable  needle-holder,  and 
threaded  with  fine  silk,  closely  insert  interrupted  sutures  by  passing  the 


Fig.  808. — Fergusson's   method.    Form- 
ing flaps,  A,  A. 


Fig.  809. — Fergusson's  method.     Uniting 
superior  flaps. 


needle  through  the  free  borders  of  the  flaps  from  the  mucous  surface  to  the 
raw,  and  from  the  raw  to  the  mucous  surface,  and  tie  them  as  you  proceed 
from  before  backward,  all  the  knots  being  situated  on  the  nasal  side  (Fig. 
809). 


Pig.  810. — Fergusson's  method.     Uniting  Fig.  811. — Fergusson's  method.    Final 

inferior  flap.     C,  0,  C.  Final  step  (Fig.  step;  formation  of  periosteal  flaps. 

811)  precedes  complete  closure. 


628  OPERATIVE  SURGERY. 

"  3.  Take  the  same  needle  and  needle-holder  and  complete  a  row  of 
interrupted  stitches  of  horsehair  on  the  buccal  surface  of  the  palate  from  the 
tip  of  the  uvula  forward,  and  tie  them  where  apposition  is  possible  without 
tension.  The  soft  structures  of  the  hard  palate  can  not  be  brought  together 
until  the  next  step  of  the  operation  is  taken  (Fig.  810). 

"  4.  Place  the  forefinger  of  the  left  hand  on  the  hamular  process ;  take 
a  short,  strong,  slightly  curved,  narrow-bladed  knife,  and  make  a  curvilinear 
incision  on  one  side,  beginning  just  behind  the  hamular  process,  cutting 
down  to  the  bone  and  extending  forward  along  the  alveolar  process,  as  far 
as  desired;  prevent  haemorrhage  by  pressure  with  the  finger  and  gauze; 
rapidly  raise  the  mucoperiosteal  flap  with  a  strong  periosteal  elevator,  from 
the  segments  of  the  hard  palate,  and  immediately  pack  the  wound  firmly 
with  iodoform  gauze.  Eepeat  this  performance  on  the  opposite  side,  and 
tie  the  horsehair  stitches  not  already  secured  (Fig.  811).  The  soft  struc- 
tures of  the  hard  and  soft  palate  are  beautifully  held  in  apposition  without 
tension  on  the  stitches. 

The  Remarks. — "  In  packing  the  iodoform  gauze  in  the  wounds,  fixation 
points  are  obtained  by  forcing  some  of  it  into  the  bone,  and  also  between  the 
teeth  and  under  the  mucous  membrane.  If  this  is  properly  carried  out, 
the  gauze  will  remain  in  place  for  a  week,  and  sometimes  longer.  It  is 
removed  when  it  becomes  loosened,  by  which  time  it  has  generally  fulfilled 
its  usefulness.  A  second  and  occasionally  a  third  packing  may  have  to  be 
inserted. 

"  It  will  be  observed  that  this  is  not  a  flap-splitting  but  a  flap-formation 
operation,  the  flaps  carrying  with  them  two  narrow  strips  of  the  firm,  strong, 
buccal  mucous  membrane  of  the  palate,  which  holds  sutures  securely,  and 
when  they  are  turned  upward  and  held  in  coaptation  by  means  of  the  first 
row  of  sutures  they  form  an  ideal  protecting  roof  to  the  raw  surfaces  be- 
neath them,  and  afford  twice  the  width  of  denuded  tissues  for  apposition, 
and  the  nasal  mucopurulent  discharge  is  shed  off  to  either  side." 

Regarding  after-treatment,  Fergusson  says  that  every  two  or  three  hours 
the  mouth  should  be  washed  with  boric-acid  solution,  and  after  the  child 
has  taken  nourishment  it  should  be  given  a  little  whisky  and  water  to  wash 
the  liquid  food  off  the  area  operated  upon.  It  is  usually  necessary  to  give 
nutritive  enemata.  The  stitches  are  not  taken  out  earlier  than  the  twelfth 
day.     If  the  child  cries  much  it  will  be  necessary  to  give  an  opiate. 

The  following  cases,  he  regards,  are  suitable  for  this  operation : 

1.  When  the  cleft  in  the  hard  palate  is  not  wider  than  half  an  inch. 
If  it  is  wider  than  half  an  inch,  it  will  be  necessary  first  to  perform  a  pre- 
paratory crowding  operation  (page  625). 

2.  The  mucous  membrane  covering  the  inner  edge  of  each  bone  seg- 
ment should  be  thick,  and  well  nourished.  If  it  is  not,  the  crowding  opera- 
tion must  be  first  performed. 

3.  The  operation  is  adapted  for  all  clefts  of  the  soft  palate  alone. 
Fergusson  maintains  that  the  results  of  this  method  are  vastly  better 

than  are  obtained  by  any  other.     The  turning  of  the  mucous  surface  flaps 
upward  lessens  considerably  the  danger  of  sepsis. 


PLASTIC  SURGERY.  629 

The  General  Comments. — The  palatine  vessels  running  along  the  base 
(see  Fig.  797,  c)  of  the  alveolar  process  will  be  divided  unless  great  care  be 
exercised.  Since  these  vessels  run  between  the  periosteum  and  mucous 
membrane  they  are  much  less  likely  to  be  injured  in  the  formation  of  muco- 
periosteal  than  mucous  flaps.  However,  the  bleeding  can  be  readily  con- 
trolled by  pressure  and  ligature.  In  order  that  the  undermost  flap  may 
be  easily  and  smoothly  swung  into  place,  it  may  be  necessary  to  loosen  its 
base  quite  freely  from  the  underlying  tissues.  The  opposed  raw  surfaces 
promptly  unite,  since  the  pressure  of  the  tongue  holds  them  firmly  in  contact 
with  each  other.  Any  remaining  defects  can  be  closed  at  another  time. 
This  method  is  adapted  especially  to  young  subjects — one  and  two  years 
old — and  those  with  broad  defects,  and  in  failure  by  other  methods. 

The  length  of  the  cleft  in  the  hard  palate  has  less  to  do  with  the  cure  than 
has  the  width  of  the  palatine  arch.  If  the  latter  be  naturally  narrow,  or  be 
narrowed  on  account  of  the  width  of  the  fissure^  the  difficulty  of  closure  is 
correspondingly  increased.  The  more  arched  is  the  palate  the  easier  the 
closure;  the  flatter  it  is  the  more  difficult  the  closure  because  of  the  lack 
of  tissue  for  substantial  flaps.  A  fissure  with  a  pointed  extremity  is  more 
readily  closed  than  one  with  a  rounded  extremity.  Fissures  extending  to 
the  incisor  teeth  are  difficult  of  closure  at  that  point  because  of  the  limited 
supply  of  soft  parts  and  the  difficulty  of  separating  the  periosteum  at  times. 
A  rectangular  knife  is  sometimes  used  for  the  purpose.  The  suitable  age  is 
about  six  years,  provided  the  health  of  the  patient  be  satisfactory.  Operation 
at  two  or  three  years  of  age  is  not  advisable,  since  interference  at  this  time 
may  forestall  Nature's  efforts  at  closure,  and  therefore  prove  harmful.  It 
can  be  completed  at  one  or  more  sittings,  depending  on  the  obstacles  to  be 
overcome. 

If  the  deformity  in  the  hard  palate  be  complicated  with  a  complete  cleft 
of  the  soft  palate,  each  defect  may  be  treated  separately.  If,  however,  the 
cleft  of  the  soft  palate  be  partial,  both  can  then  be  closed  at  the  same  sitting. 
The  soft  portion  should  be  united  first,  in  the  manner  before  described,  to 
prevent  it  from  being  obscured  by  the  blood  associated  with  the  operation  on 
the  hard  palate. 

Operations  for  closure  of  a  fissure  of  the  hard  palate,  forcing  direct 
apposition  of  the  borders  of  the  fissure,  often  so  markedly  modify  the  sym- 
metry of  the  face  and  the  biting  line  of  the  teeth,  that  imperfect  mastication 
and  a  striking  facial  disfigurement  are  substituted  for  an  oral  deformity 
that  can  be  easily  closed  by  mechanical  device. 

The  After-treatment. — Anodynes  to  relieve  pain  and  secure  quiet  may  be 
needed ;  ice-water  for  the  first  four  or  five  hours,  followed  by  iced  milk  and 
barley  water  for  the  first  day  or  two,  supplemented  by  nutrient  enemata,  are 
commended.  The  mouth  should  be  thoroughly  rinsed  with  a  mild,  innocent, 
antiseptic  fluid  after  eating,  and  talking  should  be  interdicted.  Great  pains 
should  be  taken  by  the  parents  to  educate  the  child  in  speaking,  otherwise  the 
chief  aim  of  the  operation  will  fail  of  realization.  In  those  instances  in 
which  the  united  borders  of  the  cleft  render  the  velum  so  tense  as  to  prevent 
it  from  touching  the  posterior  wall  of  the  pharynx,  and  those  in  which,  on 


630 


OPERATIVE  SURGERY. 


account  of  the  great  width  of  the  fissure^  such  a  result  can  be  foreseen,  an 
artificial  appliance  should  be  employed  at  once. 

The  Results. — Closure  of  the  cleft  does  not  cure  the  defect  in  articulation. 
However,  closure  aids  much  in  the  attainment  of  better  speech,  and  often 
contributes  greatly  to  the  benefits  of  time  and  effort  in  this  regard.  Pro- 
longed vomiting  and  unskillful  pulling  or  bruising  of  the  borders  contribute 
actively  to  failure  of  operations. 

Mechanical  means  are  employed,  not  infrequently,  to  fill  the  opening  in 
both  the  hard  and  soft  parts,  and  to  provide  even  an  artificial  uvula.  The 
apparatus  is  made  of  vulcanized  rubber,  and  is  held  in  position  by  being 
attached  to  a  plate  fitted  to  the  roof  of  the  mouth.  Defects  in  the  biting 
line  can  be  remedied  by  regulation  of  the  teeth,  and  by  the  introduction  into 
the  gap  of  false  teeth  attached  to  the  plate  closing  the  fissure.  An  expert 
dental  surgeon  must  be  consulted,  since  he  is,  as  yet,  the  only  one  fully  com- 
petent to  treat  cases  by  this  method.  The  ability  to  speak  and  to  otherwise 
control  the  action  of  the  throat  and  pharynx  with  this  contrivance  is  very 
satisfactory,  in  the  majority  of  instances  equaling,  if  not  exceeding,  the 
best  results  from  an  operation. 

Staphyloplasty. — Staphyloplasty  consists  in  fiUing  in  the  gap  of  the  soft 
palate,  and  as  much  as  possible  of  the  hard,  by  a  flap  taken  from  the  pos- 
terior wall  of  the  pharynx. 

Schonhorns  Operation. — Anaesthetize  the  patient,  perform  a  preliminary 
tracheotomy,  and  introduce  the  tampon  cannula  into  the  trachea.  The  flap 
from  the  posterior  wall  of  the  pharynx  is  made  with  the  base  downward,  and 


Fig.  812. — Lane's  method, 
flap  in  place. 


Reflected 


Fig.  813. — Lane's  method  of  repair  of 
soft  palate. 


the  apex  is  carried  as  far  upward  as  possible  to  permit  of  its  introduction 
into  the  cleft  without  tension.  The  width  and  shape  of  the  flap  must  be 
determined  by  the  size  and  outline  of  the  deformity,  allowance  being  made 
for  its  normal  shrinkage.  It  should  consist  of  the  mucous  lining  of  the 
pharynx  along  with  the  subjacent  muscular  tissue.  The  fibro-mucous  cov- 
erings of  the  hard  palate  are  dissected  up  until  its  tissues  and  those  of  the 
velum  are  freely  movable.  The  borders  of  the  cleft  are  freshened,  and  the 
flap  is  brought  in  place  and  united  by  several  sutures.  The  tampon  cannula 
can  be  removed  as  soon  as  haemorrhage  has  ceased,  or,  at  the  farthest,  on  the 


PLASTIC  SURGERY.  631 

day  I'ollowiiig  the  o])cration.  The  parts  should  he  cleansed  frequently  and 
carefully  with  a  mild  antiseptic  tluid,  to  wash  away  the  abundant  secretions. 
The  sutures  sliould  he  i-cmovcd  on  the  sixtli  or  seveutli  day  followiuo;  the 
operation. 

The  Results. — Tlic  inconveniences  in  breathing.  ;ind  the  intcn-ference 
with  hearing  and  smelling  following  a  successful  operation  do  not  commend 
its  adoption. 

Lane  closed  a  residual  cleft  in  the  soft  palate  by  means  of  a  flap  taken 
from  the  mucous  membrane  at  a  suitable  point,  contiguous  to  the  gap; 
turned  this  flap  upon  a  properly  formed  pedicle  and  united  its  borders  to 
those  of  the  defects  (Figs.  812  and  813). 

Elongated  Uvula. — An  elongated  uvula  is  easily  shortened  by  seizing 
the  end  of  the  uvula  with  the  forceps,  and  removing  the  required  amount 
with  scissors,  after  the  patient  has  withdrawn  the  tongue  by  the  aid  of  a 
dry  towel.  The  little  pain  that  may  be  caused  by  the  operation  can  be 
relieved  by  the  application  to  the  part  of  a  solution  of  cocaine. 


CHAPTEE    XIII. 

OPERATIONS  ON  THE  MOUTH,  PHARYNX,  NOSE,   (ESOPHAGUS, 

AND  NECK. 


Fig.  814. — Desault's  method. 


Salivary  Fistula. — In  salivary  fistula  the  saliva  is  discharged  on  the 
external  surface  of  the  cheek  instead  of  into  the  mouth.  The  object  of  an 
operation  is  to  establish  an  internal  communication  with  the  duct  so  that 
the  external  opening  can  heal. 

Agnew's  Method. — Agnew's  method  consists  in  passing  a  good-sized 
thread  of  silk  into  the  mouth,  through  the  fistula,  from  without  inward, 

and  leaving  it  there,  removing 
the  needle,  and  attaching  to  it 
the  end  of  the  thread  remain- 
ing outside,  and  carrying  it 
through  the  tissues  into  the 
mouth  in  the  same  direction  as 
the  former,  but  not  exactly  in 
the  same  track,  thus  including 
a  small  portion  of  buccal  tis- 
sue. The  needle  is  then  re- 
moved, and  the  extremities  of  the  thread  are  firmly  tied  within  the  mouth 
or  round  the  inclosed  tissue.  A  fine  rubber  ligature  can  be  substituted 
for  the  silk.  The  loop  cuts  its 
way  through  the  tissues  grasped, 
forming  an  internal  opening, 
which  permits  the  healing  of  the 
external  one. 

Desault's  Method. — Desault 
carried  a  small  trocar  from  the 
fistulous  opening  forward  and 
inward,  entering  the  mouth  op- 
posite to  the  second  molar  tooth  (Fig.  814).  A  seton  was  drawn  into 
the  channel  made  by  the  instrument  and  retained  until  a  patent  canal 
was  formed  through  which  the  saliva  flowed,  followed  by  healing  of  the 
external  opening. 

Van  Burens  Method. — Van  Buren  cured  an  obstinate  case  by  turning 
the  end  of  the  duct  into  the  mouth  in  the  following  manner :  A  small  probe 
was  introduced  into  the  duct  from  without  to  steady  it  during  dissection 
and  indicate  its  situation  so  as  to  prevent  cutting  it.  The  distal  end  of 
the  duct  was  exposed  for  a  short  distance  by  careful  dissection,  and  was 
then  passed  into  the  mouth  through  a  small  incision  made  through  the 
632 


Fig.  815.— Richelot's  method. 


OPERATIONS  ON  THE   MOUTH.  G33 

buccal  mucous  membrane  and  confiued  there  with  horsehair  sutures.     The 
external  oi3ening  was  refreshened  and  closed  at  once. 

Richelot's  Method. — Eichelot  inserted  into  the  fistula  a  small  rubber 
tube  so  as  to  cause  one  end  to  project  slightly  into  the  mouth,  while  the 
other  end  was  cut  off  obliquely  and  so  placed  that  the  saliva  could  flow 
directly  into  the  tube  (Fig.  815).  Thereafter  the  external  wound  healed 
promptly. 

Dcgiiise's  Method. — Deguise  made  a  puncture  througli  the  fistula,  open- 
ing obliquely  backward  and  inward  to  the  inner  surface  of  the  cheek,  and 
passed  through  it  one  end  of  a 
leaden  wire  (Fig.  816).  A  sec- 
ond puncture  was  then  made 
through  the  same  external  open- 
ing, but  directed  obliquely  for- 
ward to  the  inner  surface, 
through  which  the  other  end  of 

the    wire    was    passed    into    the  Fig.  816.— Deguise's  method, 

mouth   and   united   snugly   with 

its    fellow   by    twisting.      The    parotid    secretion    promptly    followed    the 
leaden  guides  into  the  mouth,  and  the  external  opening  quickly  healed. 

Excision  of  the  Tonsil. — The  excision  of  the  tonsil  can  be  done  with 
an  ordinary  bistoury  or  with  curved  scissors,  aided  by  a  tenaculum.  The 
various  forms  of  tonsillotomes,  while  they  simplify  the  operation  by  giving 
the  operator  a  perfect  control  over  the  cutting  edge,  are  not  necessary  to 
its  execution. 

The  Removal  of  the  Tonsil  with  the  Knife  or  Scissors. — If  the  patient 
be  young  or  unable  to  exercise  self-control,  give  an  anesthetic,  or  apply  to 
the  tonsil  a  strong  solution  of  cocaine.  Cause  a  bright  light  to  shine  into 
the  open  mouth ;  depress  the  tongue ;  seize  the  tonsil  with  the  tenaculum  or 
forceps,  draw  it  inward  from  between  the  pillars  of  the  fauces,  and  with 
scissors  curved  on  the  flat,  or  with  the  probe-pointed  bistoury,  or  an  ordi- 
nary bistoury  with  the  point  guarded  by  adhesive  plaster,  sever  the  tonsil^ 
from  below  upward.  It  is  not  necessary  at  first  to  remove  the  entire  tonsil, 
since  a  curative  influence  is  often  established  by  an  incomplete  removal. 
Among  the  tonsillotomes  in  common  use  are  Mathieu's  and  Mackenzie's.  In 
using  the  instrument  the  patient  is  placed  as  before  stated,  and  the  ring  of 
the  instrument  is  adjusted  around  the  tonsil  with  the  aid  of  the  index 
finger;  the  tonsil  is  elevated  by  a  tenaculum,  or  by  a  special  hook  of  the 
instrument,  and  severed  by  pressing  the  blade  against  it. 

While  removal  of  the  tonsil  is  ordinarily  a  matter  of  but  little  signifi- 
cance, yet  the  not  infrequent  instances  of  severe  and  even  fatal  hemorrhage 
that  follow  this  act  invite  thoughtful  attention  and  care  in  any  case  before 
the  measure  is  carried  into  effect.  Severe  bleeding  from  constitutional 
causes  (from  abnormal  vascular  association,  from  uncommon  free  blood 
supply,  from  obstructed  venous  return,  are  conditions  that  cause  perplexing 
complications  at  the  bowels  and  often  fatal  results  when  they  are  incau- 
tiously invited.  Aneurism  of  the  carotid  underlying  the  tonsil  or  of  the 
42 


634  OPERATIVE  SURGERY. 

tonsil  itself  are  conditions  not  new  to  the  surgeon  of  extensive  observation. 
The  outcome  following  incision  in  any  such  cases  as  those  is  too  obvious 
to  be  open  to  doubt.  We  recall  an  instance  of  aneurism  of  the  tonsil  having 
appearances  that  might  readily  invite  the  instrumental  activity  of  an  incau- 
tious practitioner. 

The  Results. — Ai^y  undue  haemorrhage  can  be  controlled  by  ice,  pres- 
sure, and  astringents;  actual  cautery  is  rarely  needed.  In  four  instances 
the  internal  carotid  artery  has  been  wounded  by  recklessness  in  cutting  the 
tonsils.     Bleeding  may  be  controlled  by  interrupted  suture  or  adrenalin. 

Abscess  of  the  Tonsil. — In  opening  abscesses  of  the  tonsil  and  of  the 
fauces  great  care  should  be  exercised  not  to  invade  the  tissue  too  deeply  and 
endanger  the  internal  carotid.  Therefore,  attention  to  the  anatomy  of  the 
tonsil  and  its  environments  is  important  (page  644).  The  blade  of  a 
scalpel,  well  guarded^,  except  at  the  point,  with  adhesive  plaster  or  with 
sterilized  gauze,  is  often  employed  for  making  the  incision  (Fig.  817,  g). 

OPERATIONS   ON    THE   TONGUE. 

It  is  often  necessary  to  remove  the  tongue  in  part  or  entirely  on  ac- 
count of  hypertrophy  and  malignant  or  other  growths  of  its  structure. 
The  elements  of  danger  in  removal  of  the  tongue  relate  to  haemorrhage, 
which  is  increased  by  the  difficulty  in  catching  the  bleeding  points,  and  to 
the  danger  of  blood  entering  the  larynx,  both  of  which  are  emphasized  by 
loss  of  command  of  the  patient.  The  arteries  supplying  the  organ  are  the 
dorsalis  linguae,  ranine,  and  branches  from  the  ascending  pharyngeal.  The 
ranine,  the  principal  branch,  runs  along  the  under  surface  of  the  tongue 
from  the  base  to  the  apex.  The  facial  and  sublingual  arteries  are  not 
endangered  unless  the  floor  of  the  mouth  is  operated  on  in  conjunction 
with  the  tongue.  It  should  be  remembered  that  the  vessels  on  either  side  of 
the  organ  do  not  often  communicate  freely  with  each  other,  and  consequently 
ligaturing  of  the  lingual  artery  of  one  side  will  permit  of  free  incision  on 
that  side  with  but  trifling  haemorrhage.  The  buccal,  sublingual,  and  sub- 
maxillary glands  are  closely  associated  with  this  organ  in  a  surgical  sense. 

The  principal  danger  from  bleeding  arises  from  division  of  the  lingual 
arteries.  The  situation  of  the  haemorrhage  is  much  more  disturbing  than 
the  amount.  Similar  sized  vessels  divided  elsewhere  in  the  body  would 
scarcely  cause  the  least  apprehension.  Bleeding,  however,  can  be  prevented 
by  ligature  of  these  vessels  in  the  neck  (Fig.  230),  or  controlled  for  the  time 
being  by  firm  pressure  upward  on  the  floor  of  the  mouth  by  the  thumbs  of 
an  assistant,  together  with  drawing  the  base  of  the  tongue  forward  by  means 
of  the  finger  hooked  over  it.  Not  only  do  these  manipulations  control 
haemorrhage,  but  also  fix  the  floor  of  the  mouth  so  that  the  bleeding  points 
can  be  better  seen  and  more  quickly  caught. 

A  method  has  been  recommended  hy  Langenbech  to  control  the  haemor- 
rhage when  but  half  or  two  thirds  of  the  anterior  portion  of  the  tongue  is  to 
be  removed  by  cutting. 

A  long,  well-curved  needle,  armed  with  a  strong  ligature,  is  entered  at 
the  left  of  the  median  line  of  the  tongue,  behind  the  portion  to  be  removed, 


OPERATIONS  ON   THE   MOUTH.  635 

and  passed  through  to  the  right  side  and  under  surface  of  the  organ,  so  as 
to  carry  the  ligature  beneath  the  branches  of  the  lingual  artery  at  this  situ- 
ation. The  ligature  is  then  carried  through  the  right  border  of  the  tongue 
and  firmly  tied.  A  similar  procedure  is  repeated  on  the  opposite  side  of  the 
tongue.  These  ligatures  can  be  used  also  to  draw  the  tongue  forward  during 
operation.  The  introduction  through  each  nostril  into  the  pharynx  below 
the  base  of  the  tongue  of  a  rubber  tube  suitable  for  the  purposes  of  anaesthesia, 
and  the  packing  with  gauze  of  the  space  above  the  lower  extremities  of  the 
tubes,  will  prevent  the  admission  of  blood  into  the  larynx  (Fig.  825). 

The  danger  of  blood  entering  the  air  passages  can  be  obviated  by 
turning  the  head  forward  and  to  one  side.  In  fact,  when  the  head  is  thus 
placed,  and  the  mouth  widely  opened,  the  arterial  jets  will  escape  through 
the  latter,  and  thus  reduce  the  active  bleeding  in  the  mouth  to  a  minimum. 
The  important  desiderata  are  having  the  patient  and  the  tongue  under 
complete  control,  the  dangers  from  haemorrhage  are  then  insignificant. 

Preliminary  Laryngotomy. — Preliminary  opening  of  the  larynx  or  trachea, 
together  with  tamponing  of  the  pharynx,  are  wise  measures  in  those  instances 
in  which  careful,  deliberate,  and  unobscured  division  of  the  tissues  is  needed 
for  the  purpose  of  suitable  removal  of  the  disease.  In  extended  removal  of 
the  tongue  and  in  operation  on  the  floor  of  the  mouth  these  measures  find 
their  greatest  use.  If  there  be  no  fear  of  infection  at  the  seat  of  the 
operation,  the  tube  may  be  removed  as  soon  as  the  procedure  is  completed. 
Otherwise  it  should  remain  until  healthy  repair  is  established.  In  tampon- 
ing the  pharynx  with  a  sponge,  or  by  other  means,  to  prevent  the  entrance 
of  blood,  the  tongue  should  be  drawn  well  forward  at  the  time  of  introduction 
so  as  to  permit  complete  closure  of  the  pharynx  without  interfering  with 
the  necessary  manipulation  of  the  organ  for  the  arrest  of  haemorrhage,  etc. 

Before  operation,  the  mouth,  the  growth,  and  the  teeth  of  the  patient 
should  be  repeatedly  and  thoroughly  cleaned  by  the  frequent  and  free  use  of 
an  antiseptic  solution.  Irregular  and  loosened  teeth  and  dental  asperities 
should  be  removed  at  the  time  of  operation,  and  every  care  should  be 
taken  to  provide  for  the  operation  field  aseptic  cleanliness. 

Excision  of  the  Tongue. — The  tongue  may  be  removed  with  the  hnife, 
scissors,  galvanic  cautery,  ecraseur,  or  ligature.  The  last  method  and  the 
galvanic  cautery  method  should  be  excluded,  as  the  greater  length  of  time 
required  and  the  greater  pain  caused  by  the  latter,  and  the  greater  dangers 
from  haemorrhage  and  from  sepsis  of  the  former,  unfit  them  for  use.  If  the 
diseased  portion  be  small,  it  may  be  taken  away  by  the  incision  best  calculated 
to  accomplish  the  object,  since  it  is  a  bad  plan  to  secure  symmetry  at  the  ex- 
pense of  future  safety.  If  hypertrophy  involve  the  apex,  or  if  a  tumor  he 
located  at  this  situation,  either  condition  can  be  treated  by  removing  a  V- 
shaped  piece  in  the  following  manner  : 

The  Operation.  V-shaped  Incision. — Anaesthetize  the  patient ;  place  him 
in  a  suitable  position  in  a  strong  light  with  the  mouth  well  opened  by  a 
special  gag,  or  any  proper  instrument,  forced,  with  a  string  attached,  between 
the  posterior  molars.  If  the  patient  be  in  the  recumbent  posture  turn  the 
head  to  one  side,  so  as  to  collect  the  blood  in  the  hollow  of  the  cheek ;  pass 


f^    b 


Fig.  817. — Instruments  employed  in  operations  on  the  tongue,  tonsil,  and  pillars  of  the 

fauces. 

a.  For  retraction  of  cheek,  h.  Tongue  forceps,  c.  Mouth  gag.  d.  Tenaculum,  e.  Curved 
and  blunt-pointed  scissors.  /.  Volsella.  g.  Bistoury  guarded  with  adhesive  plaster. 
h.  Sponge  forceps,  i.  Bone  drill,  k.  Trachea  tube.  I.  Traction  loops,  m.  Hare-lip 
pins.  n.  Stout  wire,  o  and  p.  Curved  and  straight  bone-cutting  forceps.  Scalpels, 
forcipressure,  ligatures,  wipers,  etc.,  should  be  had  in  abundance. 


OPERvVTTONS   ON   THE   MOUTH. 


637 


a  stout  ligature  through  each  side  of  the  tongue,  just  outside  of  the  intended 
site  of  the  apex  of  the  V  incision ;  then  loop  the  ligatures  and  give  each  to 
an  assistant  with  instructions  to  pull  the  tongue  forward;  seize  the  tip  of  the 
tongue  with  a  forceps,  or  with  the  thumb  and  finger,  and  with  a  sharp- 
pointed,  narrow-bladed  knife  transfix  the  organ  posteriorly  from  below  up- 
ward in  the  median  line,  thus  locating  the  point  of  the  V,  and  cut  outward 


Fig.  818. — Removal  of  V-shaped  piece. 


Fig.  819.— Flaps  united. 


and  forward  through  one  border  of  the  tongue.  Check  the  points  of  severe 
hemorrhage  with  forceps;  make  the  division  on  the  opposite  side  in  a  re- 
verse direction  from  the  border — backward — to  join  the  site  of  commence- 
ment of  the  first  incision  (Fig.  818).  Ligature  the  bleeding  points  and  unite 
the  flaps  by  sutures  in  the  usual  manner  (Fig.  819). 

Hypertrophy  of  the  Tongue  (Fig.  820).— Hypertrophy  of  the  tongue 
involving  its  entire  structure,  can  be  treated  by  the  removal  of  a  V-shaped 
piece  in  the  manner  just  described,  thus 
shortening  the  transverse  diameter  and 
diminishing  the  length.  The  flaps  are 
then  united,  and,  after  union  has  taken 
place,  the  thickness  of  the  tongue  can  be 
diminished  in  the  following  manner:  A 
strong  ligature  is  passed  laterally  through 
the  organ  near  to  the  base,  by  which  the 
tongue  is  drawn  forward  and  held,  while 
a  wedge-shaped  piece  is  removed  by  lat- 
eral transfixion  in  a  longitudinal  direc- 
tion, begun  midway  between  the  upper  and 
lower  surfaces  of  the  organ  as  far  back  as 
possible.  The  under  flap  is  made  by  cut- 
ting downward,  outward,  and  forward 
through  the  imder  surface  of  the  tongue ; 

the  upper  by  division  of  the  tissue  above  Fig.820.— Hypertrophy  of  the  tongue. 
the   last   incision.      The   bleeding   points 
should  be  ligatured  and  the  flaps  united  with  sutures. 

Half  of  the  organ  can  be  removed  through  the  mouth  by  first  ligaturing 
the  lingual  artery  corresponding  to  the  side  of  operation,  after  which  two 


638  OPERATIVE  SURGERY, 

long,  stout  ligatures  are  passed  through  the  tongue  near  the  tip,  one  on  each 
side  of  the  median  line,  by  means  of  which  the  tongue  is  drawn  forward  and 
upward ;  the  frenum  and  the  mucous  membrane  beneath  the  tongue  are  cut 
with  scissors  back  to  the  base  of  the  organ ;  the  tongue  is  then  divided  in 
half  from  before  backward  with  a  knife  or  scissors ;  its  deeper  tissues  are 
separated  by  tearing  with  the  finger  or  the  handle  of  the  knife,  and  the  por- 
tion to  be  removed  is  finally  severed  with  scissors.  The  remaining  half  can 
be  removed  in  a  similar  manner. 

The  Comments. — The  contention  on  the  part  of  some  surgeons  that  the 
entire  tongue  should  be  excised  when  removal  of  half  of  the  organ  appears 
needful,  has  many  strong  and,  it  seems  to  me,  wise  objections  offered  to  the 
practice.  Half  of  the  tongue,  although  deformed  by  healing,  still  has  re- 
maining, in  a  crippled  state,  the  functions  that  characterize  the  organ  in 
health,  such  as  speaking,  swallowing,  tasting,  etc.  The  moral  effect  on  the 
patient  of  a  proposition  to  remove  the  entire  organ  at  the  outset  will  too 
often  lead  to  a  rejection  of  the  operation,  thereby  causing  delay  which 
may  render  unserviceable  any  operative  procedure.  Finally,  if  removal  of 
but  half  of  the  organ  affords  only  temporary  respite,  the  remainder  can  then 
be  taken  away  with  no  greater  danger  than  that  attending  the  removal  of  the 
whole  in  the  first  instance.  Hueter  suggests  that,  in  excision  of  the  anterior 
portion  of  one  side  of  the  tongue,  the  gap  be  closed  at  once  by  using  as  a 
flap  for  that  purpose  the  apex  of  the  remaining  portion.  The  advantages 
that  may  follow  this  practice  are  measured  by  the  comparative  differences 
resulting  from  prompt  union  with  a  shortened  organ  and  those  of  one 
crippled  by  the  cicatricial  influences  of  prolonged  healing.  Hueter's  sugges- 
tion in  this  regard  is  not  often  followed. 

The  Removal  of  the  Entire  Tong'ue.— The  removal  of  the  entire  tongue 
can  be  done  through  the  mouth,  beneath  the  inferior  maxilla,  by  division 
at  the  lower  jaw  either  at  the  symphysis  or  at  one  side  of  it,  or  through 
the  cheek.  It  can  be  removed  through  the  mouth  by  means  of  the  Tcnife^ 
the  scissors,  the  galvano-cautery,  and  the  ecraseur. 

The  Operation  through  the  Mouth. — Put  the  patient  thoroughly  under 
the  influence  of  an  ansesthetic  at  the  outset,  as  afterward  only  partial  in- 
sensibility is  desired  ;  gag  the  mouth,  and  support  the  head  so  that  the  blood 
will  escape  externally  rather  than  into  the  pharynx.  Pass  a  stout  thread 
through  the  tongue  at  the  juncture  of  the  middle  and  anterior  thirds  ;  draw 
the  organ  forward  and  upward  with  the  thread,  and  detach  it  with  scissors 
from  its  connections  with  the  jaw  and  anterior  pillars  of  the  fauces ;  divide 
the  muscles  of  the  tongue  with  strong,  straight,  blunt-ended  scissors  back  to 
near  the  larynx,  as  closely  to  the  under  surface  as  the  disease  will  permit. 
The  glosso-epiglottidean  folds  are  now  brought  under  control  by  passing  a 
long  ligature  through  each  fold.  These  ligatures  are  allowed  to  remain  in 
situ  in  order  that  the  floor  of  the  mouth  may  be  drawn  forward  by  them 
in  the  event  of  secondary  haemorrhage  or  difficult  respiration.  The  excision 
is  then  completed  and  all  bleeding  points  are  checked. 

The  Comments. — The  frsenum  linguae  and  the  anterior  pillars  of  the  fauces 
should  be  completely  and  promptly  divided  so  as  to  permit  a  free  withdrawal 


OPERATIONS  ON  THE   MOUTH. 


639 


Pig.  821. — a.  Jaeger's  incision, 
er's  incision. 


h.  Koch- 


of  the  tongue  from  the  mouth.  Whitehead  advises  that  the  muscles  of  the 
tongue  be  rapidly  and  boldly  cut,  irrespective  of  other  than  arterial  hajmor- 
rhage,  as  the  oozing  will  be  promptly  checked  by  control  of  the  various 
arteries.  With  previous  study  and  present  caution  these  arteries  can  be 
caught  and  tied  or  twisted  before  being  severed,  after  which  the  operation 
is  promptly  completed  without  further  troublesome  hasmorrhage.  A  pre- 
liminary tracheotomy  is  advisable  in  those  cases  in  which  extensive  wound 

surfaces  and  troublesome  haemorrhage 
are  anticipated.  Infective  pneumonia 
is  obviated  in  the  former,  and  the  en- 
trance of  blood  to  the  pharynx  is  pre- 
vented in  the  latter  instance. 

The  ligaturing  of  the  lingual  arteries 
beneath  the  hyoglossus  muscles  before 
the  employment  of  the  scissors  for 
removal  of  the  tongue  simplifies  the 
operation  exceedingly,  as  then  the  dan- 
gers and  annoyance  of  present  or  pros- 
pective haemorrhage  are  largely  obvi- 
ated. Now  and  then  a  dorsal  lingual 
branch  requires  attention.  The  author 
has,  however,  noted  but  one  instance 
of  this  kind  in  his  own  practice.  Nor 
is  this  all,  for  the  ligature  of  these  ves- 
sels affords  opportunity  for  the  removal  of  the  lymph  glands  associated 
directly  with  the  affected  part  of  the  tongue,  whether  they  are  diseased  or 
not,  a  measure  of  far  greater  importance  in  our  opinion  than  that  of  liga- 
ture of  the  vessels.  In  fact  it  is  our  practice,  and  we  believe  that  it  should 
be  made  the  first  step  of  operative  endeavor,  to  remove  these  glands,  tying 
the  lingual  or  not  as  may  then  seem  wise. 

The  After-treatment. — Wash  the  floor  of  the  mouth  cautiously  with  a  solu- 
tion of  biniodide  of  mercury  (1  to  1,000),  dry  it,  and,  if  desirable,  paint  the  raw 
surface  with  the  antiseptic  varnish  of  Whitehead,  which  is  compounded  by 
substituting  for  the  rectified  spirits  in  the  compound  tincture  of  benzoin  a 
mixture  of  nine  parts  of  ether  and  one  of  turpentine  saturated  with  iodo- 
form. Before  using  the  ether  add  one  part  of  turpentine  to  ten  of  that  fluid. 
The  mixture  dries  quickly  and  remains  as  a  firm  coating  for  twenty-four 
hours.  Gauze  packings  are  regarded  as  objectionable  by  some,  as  they  be- 
come quickly  saturated  with  saliva.  Treves  makes  "  no  applications  of  any 
kind  "  other  than  antiseptic  solutions. 

Kocher''s  Method. — Kocher  recommends  the  following  plan  if  the  floor  of 
the  mouth  and  contiguous  glands,  and  even  the  pharynx  be  involved  along 
wHh  the  tongue :  After  a  preliminary  laryngo-tracheotomy  and  thorough 
cleansing  of  the  parts,  a  triangular  flap  is  made,  with  the  base  upward,  its 
lower  boundaries  corresponding  to  the  course  of  the  digastric  muscle,  and 
its  apex  being  at  the  point  of  connection  of  this  muscle  with  the  hyoid 
bone  (Fig.  821,  h).     The  posterior  incision  may  also  be  made  from  the  apex 


640  OPERATIVE  SURGERY. 

directly  to  the  anterior  border  of  the  sterno-mastoid  muscle,  thence  up- 
ward along  this  border  to  the  angle  of  the  jaw,  thus  affording  a  greater 
space  than  is  secured  by  the  former  line  of  incision.  This  flap  covers  the 
region  of  the  jaw  and  neck  occupied  by  the  facial  artery  and  the  submaxillary 
glands  posteriorly,  and  the  lingual  artery  and  the  sublingual  glands  anteriorly. 
The  flap  is  dissected  up,  the  arteries  are  tied,  and  the  glands  are  removed. 
This  exposes  the  side  of  the  base  of  the  tongue  and  the  back  part  of  the  floor 
of  the  mouth  to  easy  inspection  and  manipulation.  The  larynx  and  pharynx 
are  then  protected  from  the  entrance  of  blood  by  a  large  sponge,  to  which  a 
string  should  be  attached,  and  the  myo-hyoid  muscle  is  divided  close  to  the 
jaw,  exposing  the  tongue  and  mouth  freely.  The  organ  is  now  drawn  through 
the  opening,  split,  and  the  half  of  it  on  the  side  corresponding  to  the  flap  is 
removed,  including,  if  necessary,  the  floor  of  the  mouth,  pillars  of  the  fauces, 
and  pharynx,  down  to  the  hyoid  bone.  The  remaining  portion  can  be  re- 
moved in  a  similar  manner  through  a  triangular  opening  on  the  opposite 
side  or  through  the  primary  opening,  if  the  extent  of  the  disease  will  permit. 
As  before  remarked,  the  operation  which  involves  the  bone  and  soft  parts 
around  it  results  less  favorably  than  when  the  tongue  is  removed  through 
the  mouth  by  the  methods  described. 

The  Comments. — The  lingual  artery  at  either  side  may  be  tied  before  the 
flaps  are  turned  up,  or  they  may  be  ligatured  afterward,  as  suits  the  desire 
of  the  surgeon.  If  the  entire  tongue  be  removed  at  one  side,  the  lingual 
artery  of  the  opposite  side  should  be  tied  before  the  removal. 

The  After-treatment  consists  in  keeping  the  mouth  well  cleansed,  while 
to  the  raw  surfaces  iodoform  and  iodoform  gauze  or  other  suitable  anti- 
septic dressings  are  applied.     The  tracheotomy  tube  should  not  be  removed 
until  all  dangers  from  inflammation  and  from 
infective  pneumonia  due  to  the  discharges  are 
ended. 

The  Removal  of  the  Tongue  with  Division 
of  the  Jaw  does  not  offer  the  chances  of  success 
secured  by  the  preceding  method. 

Sedillofs  Method. — Beginning  at  the  median 

line  of  the  lower  lip,  divide  the  soft  parts  verti-  |  ^  f    £ 

cally  downward  to  the  hyoid  bone  (Fig.  823,  a) ;        j:  ^      |^ 

extract  a  central  incisor  tooth  and  drill  a  small    /^  ''^.. 

hole  through  the  body  of  the  lower  jaw  at  either   Fig.  832.— a.  Incision  of  Sedil- 

side,  a  quarter  of  an  inch  from  the  median  line ;        lot,  Roux,  Syme.     h.  Reg- 
'      ^  T        T  X-      11  noil  s  incision,     c.  Billroth  s 

divide  the  jaw  in  the  median  line  vertically  or        incision. 

irregularly — the  latter  affords  opportunity  for  a 

more  substantial  subsequent  coaptation;  pass  a  strong  ligature  through  the 

tongue  and  separate  the  bony  fragments,  thus  exposing  to  view  the  floor  of 

the  mouth.     Divide  the  mucous  membrane  at  its  connection  with  the  jaw, 

also  the  genio-hyoid  and  genio-hyoglossi  muscles;  draw  the  tongue  forward 

and  sever  the  remaining  attachments  carefully  with  scissors,  securing  the 

ranine  vessels  before  their  division.     The  tongue  may  be  either  removed 

entire  or  split  and  each  half  removed  separately,  as  before  described.    Unite 


OPERATIONS  ON   THE  MOUTH. 


641 


the  jaw  with  silver  wire;  drain  the  wound  from  the  lower  angle;  fortify  the 
line  of  junction  of  the  jaw  with  an  interdental  splint  (Fig.  826);  unite  the 
stump  of  the  tongue  to  the  sides  of  the  mouth  and  maintain  thorough  clean- 
liness b}-  the  frequent  employment  of  antiseptic  solutions. 

Jaeger's  Metliod. — Jaeger  divided  the  cheek,  from  the  angle  of  the 
mouth  back  to  the  anterior  border  of  the  masseter  muscle  (Fig.  821,  a),  and 
approached  the  diseased  tongue  in  this  manner.  This  measure  is  serviceable 
in  instances  in  which  the  disease  is  located  far  back  on  the  tongue,  and  in 
which  the  aaiterior  pillar  of  the  fauces  is  invaded,  also  in  the  event  of 
inefficient  light,  severe  haemorrhage,  an  uncontrollable  patient,  or  a  limited 
separation  of  jaws.  If  scarring  be  of  special  significance,  other  means  of 
attainment  of  the  objects  should  be  considered. 

The  employment  of  the  ecraseur,  as  practiced  by  Mr.  Baker,  is  a  satis- 
factory means  of  removing  the  tongue. 

Bal-er's  Method  (ecraseur). — Pass  through  each  side  of  the  tongue,  one 
inch  from  the  extremity  and  half  an  inch  from  the  median  line,  a  strong 
silk  ligature,  which  is  firmly  tied  and  looped ;  the  operator,  holding  one  loop 
while  the  assistant  holds  the  other,  causes  the  tongue  to  be  drawn  forward, 
and  then  with  a  blunt-pointed  scalpel, 
aided  by  the  fingers,  splits  the  tongue 
in  the  median  line  back  to  a  point  one 
inch  behind  the  cancerous  growth; 
arrest  ha?morrhage,  draw  the  diseased 
half  still  farther  forward,  sever  the 
muscular  and  mucous  connections  at 
the  symphysis,  and  with  sharjJ-pointed 
scissors  divide  the  mucous  membrane 
backward  along  the  lower  jaw  to  one 
inch  behind  the  site  of  the  growth. 
Free  the  diseased  portion  of  the  organ 
from  its  attachments  so  as  to  readily 
permit  the  application  of  the  ecraseur 
and  the  division  of  the  segment  at  a 
point  as  far  as  possible  from  the 
growth ;  pass  two  strong,  blunt-pointed 
curved  needles  through  the  tongue  far  behind  the  seat  of  the  disease,-  and 
adjust  the  loop  of  the  ecraseur  around  the  segment  behind  and  below  them, 
so  as  to  cause  it  to  pass  wide  of  the  disease  at  the  line  of  severance.  Baker 
employed  a  whipcord  loop  (Fig.  823)  with  a  moderate-sized  instrument, 
curved  somewhat  on  the  flat  at  the  lower  end.  Vessels  which  may  remain 
unsevered  after  tightening  the  loop  are  ligatured  and  divided,  and  the 
nerves  are  severed  close  to  the  stump.  If  necessary,  the  remaining  half  of 
the  tongue  is  treated  in  a  similar  manner.  The  instrument  can  be  applied 
to  the  tongue  through  an  opening  made  behind  the  symphysis.  The  loop 
can  be  introduced  here  so  as  to  command  half  or  all  the  tongue. 

The  Precautions. — As  the  loop  is  tightened  around  the  tongue,  care 
must  be  observed  to  prevent  it  from  slipping  forward  nearer  to  the  seat  of 


Fig.  823. — Whipcord  loop  applied. 


642 


OPERATIVE  SURGERY. 


the  disease,  which  is  liable  to  happen  notwithstanding  the  restraining  influ- 
ences of  the  transfixion  needles  and  of  the  shallow  grooves  made  in  the  soft 
parts  for  the  lodgment  of  the  loop.  Since  the  nerve  and  the  vessels  often 
escape  the  effect  of  the  loop,  the  loop  should  be  withdrawn  carefully,  the 
nerve  cut,  and  the  artery  caught  and  tied  to  avoid  embarrassing  hemorrhage. 

Reg  noil's  Method. — The  operation  devised  by  Eegnoli  affords  easy  access 
to  all  portions  of  the  tongue,  except  its  base,  and  also  furnishes  good  drain- 
age, but  creates  a  large  and  somewhat  dangerous  wound. 

The  Operation. — An  angular  or  crescent-shaped  incision  is  carried 
along  the  base  of  the  lower  jaw  (Fig.  822,  l)  extending  between  the  anterior 
borders  of  the  masseter  muscles,  avoiding  the  facial  arteries.  A  vertical 
incision  is  then  made  from  the  center  of  this  to  the  median  line  of  the 
hyoid  bone.  The  flaps  are  reflected,  the  mucous  membrane,  the  attachments 
of  the  lingual,  hyoid,  and  digastric  muscles  divided  from  the  inner  surface 
of  the  lower  jaw,  and  the  tongue  is  freed  laterally  from  the  anterior  pillars 
as  in  other  methods.  The  tongue  is  then  drawn  through  the  opening  and 
severed  by  the  knife  or  scissors,  the  bleeding  points  being  secured  as  fast  as 
they  appear.  The  flaps  are  imited,  the  wound  is  drained,  and  the  remaining 
raw  surfaces  are  allowed  to  heal  by  granulation. 

Billroth  made  a  somewhat  curved  su.bmental  incision  (Fig.  823,  c)  only, 
and  extended  it  at  either  side  so  as  to  permit  ligature  of  the  lingual  arteries 
and  removal  of  the  infected  glands 
before  extirpation  of  the  tongue 
(Fig.  824). 


Fig.  824. — Tongue  exposed  through 
Billroth's  submental  incision. 


Fig.  825. — Langenbeck's  incision,  floor  of 
mouth  involved.  Tubes  entering  pharynx 
through  nose  for  anassthetic  purposes 
(page  635). 


If  the  floor  of  the  mouth  were  involved  in  addition  to  the  tongue,  Billroth 
made  an  incision  about  one  inch  below  the  border  of  the  lower  lip,  from 
one  facial  artery  to  the  other;  at  either  end  of  this  incision  he  made  a 
vertical  one  extending  downward  to  a  point  about  four  fifths  of  an  inch 
below  the  lower  border  of  the  inferior  maxilla ;  at  the  sites  of  juncture  of 
these  vertical  incisions  with  the  jaw  he  divided  the  bone  and  turned  it 
downward  along  with  the  soft  parts,  thereby  affording  ample  room  to  reach 
the  diseased  parts  within.  After  extirpation  of  the  disease,  he  wired  the  frag- 
ments in  position  and  closed  the  wound.    LangenhecJc  (Fig.  825)  divided  the 


OPERATIOXS   ON  TDE   MOUTH.  543 

jaw  on  the  side  of  the  greatest  amount  of  disease,  drew  apart  the  fragments, 
excised  the  tongue,  floor  of  the  mouth,  etc.  The  jaw  was  united  as  in  the 
preceding  instance.  If  the  portion  to  be  removed  be  extensive  and  the 
danger  from  haemorrhage  great,  a  preliminary  tracheotomy  is  advisable. 
This  measure  not  alone  prevents  the  blood  from  obstructing  respiration, 
but  lessens  the  dyspnoea  frequently  caused  by  a  wide  separation  of  the  jaws. 

The  Choice  of  Method. — In  the  choice  of  method  Treves  wisely  presents 
the  following  propositions : 

"  1,  The  organ  should  be  removed  by  cutting  either  with  scissors  or  with 
the  bistoury. 

"  2.  The  removal  should,  as  a  general  rule,  be  effected  through  the  mouth. 
(Simple  removal  in  202  cases,  of  whole  or  part  of  organ,  14  died  (Butlin).) 

"  3.  Every  means  should  be  taken  to  reduce  the  haemorrhage  to  a  mini- 
mum. 

"  4.  When  the  floor  of  the  mouth  is  involved,  or  the  glands  are  exten- 
,sively  diseased,  the  excision  should  be  carried  out  through  the  neck." 

The  General  Remarks. — Cancer  of  the  tongue  causes  infection  of  lymph 
glands  speedily,  and  prompt  action  should  be  counseled  in  all  instances. 
Therefore,  an  accurate  knowledge  of  the  nature  of  a  morbid  growth 
of  the  tongue  should  be  quickly  gained,  and,  too,  before  the  employment 
of  irritating  applications.  When  the  disease  is  located  at  the  franum  it 
is  difficult  of  removal  and  of  proper  esti- 
mation of  the  extent  without  first  ex- 
tracting two  or  three  of  the  lower  incisor 
teeth.  A  suitable  vulcanite  interdental 
splint  constructed  to  fit  the  jaw  before  its 
division  is  the  best  agent  for  the  retention 
in  place  of  the  fragments  after  operation 
(Fig.  826).     It  should  not  be  overlooked 

that  in  hopeless  cases  the  removal  of  the      -^       „„„       t^.      ,    ,     . 

T .  J.  1      1  1         •  11        Fig.    826.  —  Kmgsley  s    interdental 

disease  from  the  buccal  cavity,  even  though  splint  of  vulcanized  rubber. 

it  returns  promptly  elsewhere,  rescues  the 

patient  from  the  pitiless  suffering  attendant  on   its  presence  in  the  mouth. 

The  After-treatment. — Thorough  asepsis  and  a  liberal  nutritious  diet 
are  the  elements  of  prime  significance  in  the  treatment.  Rectal  alimenta- 
tion for  the  first  two  days,  followed  by  the  use  of  the  stomach  tube,  if  neces- 
sary, is  very  important.  Abundant  fresh  air  and  cleanliness  of  the  mouth 
should  be  secured. 

The  Results. — The  rate  of  mortality  from  removal  of  the  tongue  by  all 
of  the  methods  described  is  considerable,  fifty-six  out  of  two  hundred  and 
forty-four  cases  having  died.  In  one  hundred  and  sixty-three  cases  of  re- 
moval through  the  mouth  attended  with  preliminary  ligature  of  the  Unguals 
only,  the  death-rate  was  12.8  per  cent.  In  fifty-eight  cases  operated  on  by 
Kocher,  the  death-rate  was  about  10.5  per  cent.  In  twelve  cases  done  by 
Kocher  after  his  own  method  the  death-rate  was  8.3  per  cent.  In  removal 
requiring  excision  of  the  jaw  or  extensive  dissections,  the  rate  is  increased 
five  and    ten  per   cent.      In  two    hundred  and    forty  cases    ten    per  cent 


644 


OPERATIVE  SURGERY. 


reached  the  three-year  and  6.6  per  cent  the  four-year  limit.  In  severe  cases, 
when  thoroughly  done,  the  life  limit  is  encouraging,  as  is  shown  by  the  fact 
that  half  of  Kocher's  long-lived  ones  were  of  this  character.  Whitehead 
reports  129  cases,  in  which,  so  far  as  could  be  known,  8  lived  from  3  to  10 
years,  17  succumbing  before  the  three-year  period  (Curtis).  Treves  reports 
34  cases  of  his  own  attended  with  primary  ligature  of  the  Unguals,  in  which 
3  died.  Baker  reports,  as  the  result  of  his  method,  40  cases  with  5  deaths, 
1  from  diphtheria.  Many  of  Whitehead's  cases  are  early  ones.  The  rate  in 
removal  of  glands  and  part  or  whole  of  tongue  below  jaw  is  5  per  cent  better 
than  Avith  division  of  jaw.  Unoperated  cases  live  scarcely  more  than  a  year. 
Tongue-tie. — Tongue-tie  depends  on  an  undue  extension  forward,  either 
with  or  without  an  abnormal  shortening  of  the  frsenum  linguae.  If  the 
condition  be  severe  enough  to  call  for  treatment,  the  end  of  the  tongue  is 
pressed  upward  by  passing,  the  first  two  fingers  beneath  it,  palm  downward, 
bringing  the  tense  f  raenum  between  them,  which  can  be  divided  with  a  blunt- 
pointed  scissors  at  a  little  distance  from,  but 
parallel  with  the  palmar  surface,  care  being 
taken  not  to  sever  the  ranine  artery. 

Ranula  (Fig.  827). — The  closure  of  the 
ducts  of  the  sublingual  and  other  glands  in 
this  situation  causes  a  cystic  distention  of 
them,  and  even  of  the  glands  themselves.  If 
it  is  not  possible  to  find  and  probe  the  duct 
openings,  it  will  be  necessary  to  evacute  the 
contents  at  the  floor  of  the  mouth  below  the 
tongue,  or,  if  the  tumor  be  of  large  size,  this 
must  be  done  in  the  median  line  externally, 
close  to  the  hyoid  bone.  In  either  instance 
it  may  be  necessary  to  pack  the  cavity  with 
lint  and  liquor  ferri  suljshatis,  or  cauterize 
the  sac  with  nitrate  of  silver  or  carbolic  acid,  and  even  to  dissect  it  partially 
or  entirely  away.  The  use  of  stimulating  injections,  the  introduction  of  a 
seton  of  silk  medicated  with  an  astringent  or  stimulant,  or  the  division  and 
stitching  outward  of  a  portion  of  the  wall  of  the  cyst,  may  be  practiced  if 
simpler  means  fail.     Secondary  sacs  should  be  opened  to  permit  cure. 

Removal  of  Tumor  of  Tonsil  and  Pillar  of  Fauces. — This  operation  is 
practiced  for  the  purpose  of  removal  of  malignant  disease  of  the  tonsil,  with 
or  without  involvement  of  contiguous  tissues.  In  the  simpler  forms  the 
disease  can  be  removed  through  the  mouth.  But  if  the  disease  be  exten- 
sive, and  evidences  of  deep  tissue  and  lymphatic  involvement  be  noted,  the 
approach  should  be  made  from  the  neck  (pharyngotomy).  In  either  in- 
stance a  careful  study  of  the  important  nervous  and  vascular  relations  to  the 
diseased  structure  should  be  made. 

The  Anatomical  Points. — The  tonsil  in  health  corresponds  to  the  angle  of 
the  lower  jaw.  It  is  a  vascular  structure  receiving  branches  from  the  facial, 
internal  maxillary,  lingual,  and  ascending  pharyngeal  arteries.  The  internal 
carotid  lies  at  the  outer  and  posterior  aspect  of  the  tonsil,  at  a  distance  of 


Fig.  837.— Ranula. 


OPERATIONS   ON   THE   PHARYNX. 


645 


about  three  fourths  of  an  inch,  separated  from  it  by  the  muscular  and 
fibrous  structures  of  the  pharynx,  tlie  styloglossus,  and  stylopharyngeus 
muscles.  The  glosso-pharyngeal  nerve  has  a  substantially  similar  associa- 
tion. The  removal  of  the  tonsil  for  malignant  disease  can  be  carried 
on  through  the  mouth  or  through  an  incision  in  the  neck.  The  former 
route  is  advisable  when  the  growth  is  limited  to  the  tonsil,  and  even  extends 
to  the  base  of  the  tongue,  and  is  not  attended  with  glandular  involvement. 
In  some  instances  either  tracheotomy  with  pharyngeal  plugging,  or  splitting 
of  the  cheek,  and  ligature  of  the  external  carotid,  may  be  practiced,  especially, 
the  latter,  if  for  no  other  reason  than  that  of  lessening,  for  a  time,  at  least, 
the  blood  supply  of  the  diseased  part. 

The  Ojjeration. — Fix  the  mouth  widely  open  with  the  gag  and  raise  the 
shoulders  so  as  to  expose  the  parts  to  a  good  light;  seize  the  diseased  tonsil 
with  forceps  or  tenaculum,  and  draw  it  well  into  the  mouth,  then  with  long, 
blunt-pointed  scissors  divide  the  tissues  cautiously  and  as  far  away  from 
the  growth  as  advisable,  arresting  haemorrhage  with  sponge  pressure,  tor- 
sion, etc.,  as  it  appears.  If  the  disease  has  extended  beyond  the  tonsil  to 
the  pillars  of  the  fauces,  divide  the  soft  palate  near  to  the  median  line, 
thence  outward  with  scissors,  and  finally  remove  the  pillars  of  the  fauces 
and  the  tonsil  by  means  of  blunt  dissection  carried  on  with  the  scissors, 
fingers,  or  an  instrument  devised  for  the  purpose.  If  it  so  happens  that  the 
large  size  of  the  growth  interferes  with  the  visual  or  manipulative  oppor- 
tunities of  the  surgeon,  the  growth  may  be  reduced  in  size  by  the  galvano- 
cautery  knife  at  a  dull  red  heat.  Forcipressure  and  sponge  pressure  usually 
meet  the  hgemostatic  requirements. 

Pharyng-otomy  (Cheever's  method,  Fig.  828). — Make  an  incision  through 
the  integument,  platysma,  and  fascia  along  the  anterior  border  of  the  sterno- 
mastoid  muscle  from  the  level  of  the  lobe  of  the  ear 
to  below  the  level  of  the  tumor ;  make  a  second  one 
extending  from  the  first  along  the  body  of  the 
lower  jaw ;  dissect  and  draw  aside  the  flaps ;  avoid, 
if  possible,  the  lower  branches  of  the  facial  nerve; 
divide  the  stylo-hyoid,  styloglossus,  stylo-pharyn- 
geus,  and  the  digastric  musdes,  if  need  be ;  ligature 
and  divide  the  facial  artery  and  vein ;  draw  the  sub- 
maxillary gland  forward,  and  the  internal  jugular 
vein  and  carotid  arteries  outward,  exposing  the 
pharyngeal  wall.  Introduce  the  forefinger  into  the 
mouth  and  outline  the  extent  of  the  disease,  aided 
by  conjoined  manipulation  from  without.  Open  the 
pharynx  in  front  of  the  disease  from  without  with  a 
galvano-cautery  knife  or  with  scissors,  thence  passing 
upward,  backward,  and  downward,  circumscribing 
the  disease  widely  and  removing  it  along  with  the  con- 
tiguous portion  of  the  wall  of  the  pharynx,  leaving  no  lymphatic  glandsbehind. 

The  Remarks. — The  author,  in  a  recent  severe  case  requiring  excision  of 
the  ascending  ramus  of  the  jaw,  carried  the  first  {a  h)  incision  along  the  lower 


Fig.  828.— a  h  c.  Cheever's 
incision,  a  c.  Mikulicz's 
incision.  — .  Author's 
secondary  incision  to  a  b. 


646  OPERATIVE   SURGERY. 

border  of  the  horizontal  ramus  of  the  jaw  instead  of  in  the  course  described 
above.  The  second  incision  (dotted  line)  was  made  backward  and  down- 
ward from  near  to  the  center  of  the  first,  and  the  flaps  were  reflected  in 
the  usual  manner.  On  closing  the  external  wound,  the  lower  end  of  the 
second  incision  was  situated  admirably  for  the  purposes  of  dependent 
drainage. 

Czerny''s  Method. — Introduce  a  tracheotomy  tube,  and  tampon  the 
pharynx ;  make  an  incision  from  the  angle  of  the  mouth  downward  and 
outward  to  the  anterior  border  of  the  masseter,  thence  downward  to  the  level 
of  the  hyoid  bone ;  expose  and  divide  the  lower  jaw  just  in  front  of  the  last 
molar  tooth ;  draw  the  fragments  apart  and  divide  the  buccinator,  digastric, 
styloglossus,  stylo-hyoid,  and  stylopharyngeus  muscles ;  secure  the  facial  and 
lingual  vessels ;  avoid  the  salivary  glands,  and  the  lingual,  hypoglossal,  and 
glosso-pharyngeal  nerves.  After  removal  of  the  growth  the  jaw  is  united 
with  silver  wire,  and  the  wound  is  closed  and  dressed. 

Mikulicz's  Metliod. — Tracheotomy  and  pharyngeal  tampon  are  em- 
ployed the  same  as  before.  Make  an  incision  from  the  tip  of  the  mastoid 
process  along  the  anterior  border  of  the  sterno-mastoid  muscle  to  the  greater 
cornu  of  the  hyoid  bone.  Expose  both  surfaces  of  the  ascending  ramus  of 
the  lower  jaw  with  the  rugine,  carefully  avoiding  the  parotid  gland,  facial 
vessels,  and  external  carotid  artery ;  exsect  the  ramus,  draw  aside  with 
strong  hooks  the  body  of  the  jaw,  the  masseter,  internal  pterygoid,  digastric, 
and  stylo-hyoid  muscles,  thus  exposing  the  lateral  wall  of  the  pharynx  at 
the  situation  corresponding  to  the  tonsil.  The  pharynx  is  opened  and  the 
disease  is  removed  as  in  the  flrst  instance.  If  the  tissues  connected  with 
the  ramus  of  the  jaw  are  involved,  this  portion  of  the  bone  should  be  re- 
moved along  with  the  diseased  structures  connected  with  it.  The  elevation 
of  the  periosteum  at  the  inner  surface  in  such  cases  as  these  is  obviously  as 
unnecessary  as  it  is  unwise. 

The  General  ReniarTcs. — Treves  advises  the  passing  of  a  soft  catgut  liga- 
ture beneath  the  common  carotid,  so  that  hsemorrhage  can  be  arrested 
promptly  in  case  of  need,  by  traction  on  the  ligature,  not,  however,  by 
tying  it.  After  operation  the  ligature  is  removed  and  the  wound  closed. 
If  hgemorrhage  be  not  feared,  preliminary  ligature  of  the  external  carotid 
is  advisable,  since  this  measure  not  only  controls  hgemorrhage,  but  like- 
wise arrests  the  freedom  of  the  circulation  of  the  part  for  some  time  to 
come,  and,  moreover,  offers  no  impediment  to  cerebral  circulation.  In 
those  cases  in  which  the  external  carotid  is  tied  and  the  operation  com- 
pleted at  once,  infection  of  the  wound  from  the  pharynx  may  lead  to 
cellulitis  of  the  neck,  and  to  secondary  hgemorrhage  from  the  external 
carotid  at  the  seat  of  the  ligature.  Therefore,  in  our  last  case  of  this  kind, 
the  wound  was  packed  with  iodoform  gauze  for  three  days  before  the 
disease  was  removed.  During  this  time  reparative  closure  of  the  inter- 
stices of  the  entire  wound  had  taken  place,  and  but  a  very  limited  suppura- 
tion followed.  A  longer  time  than  this  can  be  taken  in  many  instances.  It 
is  essential  for  final  cure  that  the  lymphatic  glands  be  removed  irrespective 
of  the  appearance  in  them  of  infection,  as  it  is  a  well-established  fact  that 


OPERATIONS  ON   THE  PHARYNX.  647 

these  glands  may  be  infected  without  causing  an  appreciable  increase  in 
size.  The  glands  and  the  associated  connective  tissue  should  be  dissected 
away  together,  thus  securing  the  removal  of  infected  glandular  and  other 
lymphatic  structures.  Two  wires  should  be  introduced  through  the  frag- 
ments of  the  jaw  at  some  distance  apart,  especially  in  the  posterior  division 
of  the  bone,  to  prevent  rotation  of  the  posterior  fragment,  which  is  quite 
sure  to  happen  if  but  one  be  employed.  The  interdental  splint  (Fig.  826) 
finds  in  these  cases  a  most  satisfactory  use. 

Tlic  After-treatment. — Free  drainage,  thorough  cleanliness,  and  ample 
nutrition  by  means  of  the  stomach  tube  are  essential.  The  opening  in  the 
wall  of  the  pharynx  should  be  closed  at  once  as  far  as  possible  with  chromi- 
cized  catgut.  The  external  wound  is  closed;  drainage  and  moderate  pres- 
sure are  applied  to  the  surface.  If  an  opening  remain  in  the  pharynx, 
it  should  be  plugged  lightly  from  within  with  antiseptic  gauze  to  prevent 
infection  of  the  wound.  The  patient  should  be  got  out  of  bed  and  in  the 
fresh  air  as  soon  as  practicable.  He  should  be  caused  to  lie  on  the  well  side 
during  healing,  to  prevent  contact  with  the  raw  surfaces  of  the  buccal  dis- 
charges. 

The  Results. — Late  detection  of  the  disease,  with  consequent  involve- 
ment of  the  glands,  renders  the  final  outcome  very  unsatisfactory  indeed. 
However,  sufficiently  favorable  results  have  followed  bold  and  extended 
action  on  the  part  of  many  surgeons  to  warrant  the  attempt  of  extirpation, 
provided  proper  co-operation  can  be  secured.  Bosworth  reports  but  one  cure 
— two  and  a  half  years — in  118  cases.  Butlin  reports  54  cases,  with  14 
deaths  from  operation;  21,  alive  or  dead,  with  recurrence;  3  died  from  can- 
cer elsewhere;  9  were  free  for  more  than  three  and  8  from  one  to  three 
years.    Butlin  does  not  favor  preliminary  tracheotomy. 

Low  Lateral  Pharyngotomy  (author's  case). — The  operation  of  low 
lateral  pharyngotomy  for  the  purpose  of  reaching  the  lower  part  of  the 
pharynx,  the  upper  part  of  the  oesophagus  and  the  posterior  aspect  of  the 
larynx,  is  not  a  novel  procedure  except  in  so  far  as  may  relate  to  tumor  of 
the  larynx  itself. 

In  the  instance  in  question,  the  patient,  forty-five  years  of  age,  had  suf- 
fered for  many  months  with  a  tumor  located  apparently  at  the  lower  part 
of  the  pharynx,  so  low,  in  fact,  that  it  could  be  seen  only  with  the  aid  of  a 
laryngoscope  and  could  be  felt  only  with  much  difficulty  at  its  upper  aspect 
with  the  index  finger  introduced  through  the  mouth.  The  distance  from 
the  upper  incisor  teeth  to  the  tumor  was  five  and  a  half  inches.  The  growth 
appeared  to  fill  the  entire  pharynx  at  that  situation,  although  the  finger 
could  be  swept  around  the  upper  part  very  easily.  However,  at  a  distance 
of  six  inches  from  the  incisor  teeth  the  end  of  the  finger,  when  thus  swept, 
came  in  contact  at  the  right  border  of  the  pharynx  with  an  apparent  attach- 
ment of  the  tumor  to  that  aspect  of  the  pharyngeal  wall.  The  patient  could 
breathe  readily  except  when  in  the  recumbent  position  and  during  sound 
slumber,  then  the  presence  of  obstruction,  characterized  by  obstructive  ster- 
tor  and  difficult  breathing,  were  prominent. 

Inasmuch  as  local  treatment  had  in  no  manner  been  followed  by  benefit, 


648  OPERATIVE  SURGERY. 

it  was  determined  that  only  direct  removal  would  suffice^  and  low  lateral 
pharyngotom}^  at  the  right  was  selected  as  the  best  means  of  approach  to  the 
growth.  It  was  deemed  wise  to  direct  the  lower  portion  of  the  incision  so 
as  to  correspond  to  the  site  of  the  supposed  attachment  of  the  morbid 
growth  to  the  lateral  wall  of  the  pharynx,  thus  enabling  one  to  clearly 
define  the  important  characteristics  of  the  tumor  and  the  best  means  of 
removing  it,  i.  e.,  by  enucleation,  the  hot  loop,  or  by  ligature  or  division  of 
the  pedicle. 

With  the  head  and  shoulders  well  elevated  to  facilitate  respiration,  the 
patient  was  anaesthetized  with  <3hlorof orm.  The  approach  of  profound  anaes- 
thesia was  promptly  attended  with  such  a  degree  of  respiratory  obstruction 
as  to  require  the  employment  of  a  trachea  tube,  which  was  introduced  into 
the  larynx  in  order  to  limit  as  much  as  possible  the  capacity  of  the  space 
above  the  tube,  thus  minimizing  the  amount  of  blood  that  might  enter  the 
larynx  in  spite  of  packing  should  much  bleeding  attend  the  removal  of  the 
growth. 

The  Operation. — After  the  introduction  of  the  trachea  tube  the  head  was 
turned  strongly  to  the  opposite  side  and  an  incision  made  from  a  point  about 
an  inch  below  the  body  of  the  jaw,  in  a  line  corresponding  to  the  posterior 
border  of  the  thyroid  cartilage,  through  the  integument  superficial  fasciae  and 
platysma,  to  a  point  a  little  below  the  cricoid  cartilage.  The  borders  of  the 
incision  were  drawn  apart  and  held  by  means  of  traction  loops,  and  the  left 
greater  cornu  of  the  hyoid  bone  was  firmly  pressed  to  the  right,  thus  bring- 
ing into  prominence  the  right  greater  cornu,  which  was  then  seized  with  a 
tenaculum  and  drawn  firmly  upward  and  held,  thereby  increasing  the 
space  below  it  and  immobilizing  the  cornu,  thus  placing  on  the  stretch  and 
making  prominent  the  part  of  the  inferior  constrictor  at  the  floor  of  the 
incision,  the  thyro-hyoid  m.uscle  at  the  outer  border  and  also  the  portion 
of  the  thyro-hyoid  membrane  immediately  below  the  greater  corim,  as  well 
as  the  contiguous  borders  of  adjacent  muscles.  It  is  proper  to  note  at  this 
time  that  the  external  and  internal  branches  of  the  superior  laryngeal  nerve 
are  the  only  nerve  structures  of  special  significance  that  are  reasonably 
exposed  to  danger  from  proper  operative  advance  through  this  incision.  The 
external  branch  is  intimately  associated  with  the  part  of  the  inferior  con- 
strictor muscle  most  concerned  in  the  operation,  lying  upon,  sometimes  pierc- 
ing, its  lower  part,  perhaps  passing  quite  transversely  across,  then  again 
nearly  vertically  downward  upon  it.  However,  inasmuch  as  this  nerve  can 
be  easily  seen  in  the  great  majority  of  instances,  it  can  be  readily  avoided. 
The  internal  branch  passes  beneath  the  thyro-hyoid  muscle  with  the  superior 
laryngeal  artery,  between  the  greater  cornu  and  the  thyroid  cartilage,  and 
pierces  the  th3rro-hyoid  membrane,  going  to  its  distribution.  Often  the 
superior  thyroid  vein,  and  sometimes  the  middle,  lies  in  the  way.  In  this 
instance  a  careful  examination  of  the  floor  of  the  operation  field  disclosed 
the  external  laryngeal  nerve  lying  quite  vertically  along  the  inferior  con- 
strictor, with  the  superior  thyroid  vein  lying  transversely  somewhat  higher 
up.  The  former  was  raised,  pulled  aside  and  held,  the  latter  tied  between 
two  ligatures  and  pushed  aside.    A  half -inch  incision  was  then  made  through 


OPERATIONS  ON  THE  PHARYNX. 


649 


the  th^yro-hyoid  membrane,  just  below  the  great  cornu,  avoiding  the  internal 
branch  of  the  hiryngeal  nerve  and  the  attendant  artery,  into  the  pharynx. 

Through  this  opening  the  index  finger  was  carefully  introduced  and  the 
tumor  lying  in  front  was  closely  ex- 
amined. It  extended  from  side  to 
side,  encroaching  more  pronouncedly 
upon  the  right,  was  quite  immovable 
and  appeared  to  be  located  immedi- 
ately posteriorly  to  the  larynx  and 
firmly  attaelied  to  it.  It  was  at  once 
evident  that  it  could  not  be  entirely 
removed  by  cold  or  hot  snaring,  and 
therefore  removal  by  enucleation 
was  next  considered.  The  incision 
into  the  pharynx  was  extended 
downward  to  opposite  the  point  of 
supposed  contact  of  the  growth  to 
the  wall  of  the  pharynx,  thus  expos- 
ing the  right  side  of  the  tumor  with 
the  mucous  membrane  reflected 
above  it.  Through  this  opening  the 
index  finger  was  introduced  between 
the  tumor  and  the  reflected  mem- 
brane, and  with  patient  though 
somewhat  rigorous  caution  the  tu- 
mor was  completely  enucleated,  leav- 
ing intact  the  entire  inembranous 
envelope,  a  fact  quickly  proven  by 
introducing  into  the  sac  fluid  from 
which  none  escaped,  except  at  the 
point  of  its  entrance. 

The  RemarJcs. — The  enucleation 
showed  that  the  growth  began  at 
the  right  side  of  the  posterior  sur- 
face of  the  cricoid  cartilage  and 
increasing  gradually  in  size  had  re- 
mained covered  with  the  expanding 
overlying  mucous  membrane  of  its 
inception,  becoming  attached  as  it 
increased  to  the  posterior  surfaces 
of  the  arytenoid  cartilages  and  the 
intervening  structures.  The  right 
half,  of  the  growth  was  so  firmly 
held  in  position  by  the  right  ala 
of  the  thyroid  cartilage  that  it  was 
necessary  to  divide  with  scissors  the  ala  at  a  point  just  internal  to  the 
junction  of  its  cornu  before  the  growth  could  be  raised  from  its  bed. 
43 


Fig.  829. — Growth  removed  from  posterior 
aspect  of  larynx  by  low  subhyoid  lateral 
pharyngotomy.  Weight,  425  gr. ;  di- 
ameters, 1|  X  If  X  1^  inches.  Photo- 
graph taken  after  preservation  in  forma- 
lin.   Top  and  base  show  lines  of  section. 


650  OPERATIVE  SURGERY. 

The  opening  into  the  pharynx  was  closed  with  fine  interrupted  chro- 
micized  catgut  sutures;  the  superimposed  structures  by  buried  catgut  and 
superficial  silkworm-gut  sutures.  A  textile  fabric  drainage  agent  was 
introduced  into  the  sac  after  removal  of  the  tumor,  and  the  remaining  por- 
tion of  the  external  wound  was  lightly  packed  with  gauze.  The  borders 
of  the  divided  cartilage  were  closely  united  with  a  chromicized  catgut 
suture.  The  direct  pharyngeal  portion  of  the  wound  healed  promptly. 
At  the  end  of  the  third  day  a  limited  portion  of  fluid  injected  into  the  sac 
entered  the  pharynx  through  a  small  opening  at  the  lower  part,  caused,  no 
doubt,  by  sloughing,  since  the  foul  odor  of  the  breath  suggested  this  process. 
On  the  fifth  day  fluid  injected  into  the  sac  likewise  entered  the  larynx, 
causing  evidences  of  strangling.  No  doubt  limited  sloughing  of  the 
anterior  wall  of  the  sac  happened  about  this  time.  However,  care  in  wash- 
ing prevented  unpleasant  results  from  this  cause.  The  entire  wound  sub- 
stantially closed  at  the  end  of  nineteen  days,  the  patient  returning  home. 

According  to  Haubold,  the  first  authentic  case  of  low  lateral  pharyngot- 
omy  was  by  Cocks  in  1856,  for  removal  of  a  false-tooth  plate.  The  next 
was  by  Wheeler  in  1875  for  the  removal  of  a  needle  from  the  pharynx. 
This  operation  involved  only  the  making  of  a  small  opening  into  the 
pharynx.  Justi  in  1882  made  a  low  lateral  pharyngotomy  for  removal  of 
a  plum  pit  from  the  pharynx.  In  1884  Wheeler  removed  successfully  a 
spindle-celled  sarcoma  the  size  of  a  small  egg  from  the  pyriform  sinus  of 
the  pharynx  by  means  of  a  low  lateral  pharyngotomy.  In  1886  Wheeler 
excised  a  diverticulum  of  the  pharynx  by  an  incision  for  low  lateral  pharyn- 
gotomy and  the  patient  recovered.     In  five  previous  eases  all  recovered. 

This  ease  appears  to  be  the  first  of  removal  of  a  tumor  from  the  pos- 
terior surface  of  the  larynx  by  the  means  of  low  lateral  pharyngotomy. 

OPERATION'S    ON    THE    NOSE 

Plugging  of  the  Posterior  Nares  (Fig.  830). — Plugging  of  the  posterior 
nares  is  practiced  for  the  arrest  of  obstinate  epistaxis.  The  tampon  or  plug 
can  be  made  of  sponge,  lint,  or  of  suitable  cloth,  and  should  be  of  a  proper 
size  to  closely  fit  the  posterior  naris  of  one  side,  which  in  the  adult  is  about 
three  quarters  of  an  inch  long  and  half  an  inch  wide.  The  plug  is  made  by 
tying  a  strong  ligature  around  the  middle  of  the  selected  aseptic  material 
suitably  arranged  for  the  purpose,  the  ligature  including  within  its  grasp  at 
opposite  sides  of  the  plug  the  loops  of  two  other  strong  ligatures,  which  are 
in  turn  tied  firmly  to  the  primary  one ;  the  ends  of  the  latter  after  tying  are 
cut  short.  A  plug  of  simpler  construction  than  this  is  often  employed  (Fig. 
830).  The  cannula  of  Bellocq  (Figs.  830  and  831,  c),  with  the  spring  with- 
drawn, is  then  carried  along  the  floor  of  the  nostril  to  the  posterior  wall  of 
the  pharynx,  when  the  movable  rod  is  projected  forward  into  the  mouth.  The 
extremities  of  the  loop  at  one  side  of  the  tampon  are  passed  through  the  eye 
of  the  instrument,  with  which  they  are  drawn  through  the  meatus  by  first 
returning  the  central  rod  and  then  withdrawing  the  instrument  itself.  The 
tampon  is  now  carried  into  position  by  pulling  on  the  strings  which  have 
their  exit  through  the  nose,  aided  by  the  finger  carried  behind  the  soft 


OPERATIONS  ON  THE  NOSE. 


651 


palate.  Sufficient  traction  is  made  to  forcibly  close  the  posterior  nares ;  the 
strings  in  front  arc  then  ti(^fl  aronnd  another  plug  similar  to  that  already 
used,  l)y  which  means  the  aiitci'ior  opening  is  closed  as  well.  The  plug 
should  be  well  carbolized  Ix'fore  introduction,  and,  if  need  be,  can  be  wet 
with  an  astringent  solution.  The  plug  is  removed  at  the  end  of  forty- 
eight  hours  by  pulling 
downward  on  the  strings 
remaining  in  the  mouth 
supplemented  with  l)ack- 
ward  pressure  by  an  in- 
strument introduced  along 
the  floor  of  the  nostril.  If 
the  cannula  of  Bellocq  be 
not  available,  a  long,  flexi- 
ble prolDe,  an  ordinary  gum 
catheter  (Fig.  831,  "^c),  or 
even  a  common  wire,  may 
be  utilized  in  its  stead 
(Fig.  831,  c).  Sometimes 
the  string  is  carried  pref- 
erably through  the  nostril 
and  out  of  the  mouth  by 
means  of  the  cannula,  etc., 
or  other  instrument,  and 
then  attached  to  the  plug, 
instead  of  being  tied  to  it 
before  the  cannula  is  in- 
troduced. 

TJie  Remarhs. — If  the  plug  be  introduced  too  tightly,  sloughing  of  the 
mucous  membrane  may  ensue,  followed  even  by  necrosis  of  the  bones ;  also, 
the  removal  may  cause  quite  severe  bleeding.  If  ha?morrhage  recur  after 
removal  of  the  plug,  the  nares  should  be  thoroughly  cleansed  before  an- 
other is  introduced,  to  obviate  the  danger  of  sepsis,  a  risk  that  is  propor- 
tionate to  the  length  of  time  that  the  plug  is  allowed  to  remain  in  place 
unchanged. 

The  Removal  of  Nasal  Polypi  (Forceps  or  Snare).— If  the  polypus  or 
the  pedicle  be  small,  the  growth  can  be  quite  readily  removed  by  the 
forceps  or  the  snare. 

If  the  forceps  be  employed,  the  patient  should  sit  in  a  chair  exposed  to  a 
bright  light,  with  the  head  supported  by  an  assistant,  and,  after  spraying 
the  nares  with  a  strong  solution  of  cocaine,  the  point  of  attachment  of  the 
growth  is  seized  and  twisted  off  by  turning  the  instrument  repeatedly  on  its 
long  axis.  If  the  growth  he  attached  to  the  turhinated  hone,  it  may  be  neces- 
sary to  twist  and  pull  away  the  bone  structure  before  the  tumor  can  be 
removed.  In  such  a  case  as  this,  the  patient  should  be  placed  in  the 
recumbent  position  and  with  the  head  so  turned  as  to  cause  the  blood  to 
flow  from  the  nose  instead  of  into  the  pharynx.    An  anaesthetic  should  be  em- 


FiG.  830. — Plugging  posterior  nares. 


652 


OPERATIVE  SURGERY. 


ployed.  One  blade  of  the  forceps  is  passed  carefully  beneath  the  turbinated 
bone,  the  other  at  the  opposite  side,  and  when  closed  firmly  the  bone  is 
twisted  away  along  with  the  large,  and  often  with  numerous  small  growths. 
If  the  growth  be  situated  far  back  or  hang  down  into  the  fauces,  it  may 
be  detached  by  the  finger  passed  behind  the  soft  palate.  If  this  plan  fail, 
the  tumor  may  be  snared.  In  snaring,  the  wire  loop  (Fig.  831,  c),  without 
or  with  the  cannula  (Fig.  833),  is  passed  along  the  floor  of  the  nose  and  over 


Fig.  831. — Implements  employed  in  plugging  nares  and  in  removal  of  nasal 

growths,  etc. 
a.  Nasal  specula,     b.  Straight  and  curved  polypus  forceps,     c.  Gum  catheter,  Belloeq's 
cannula,  and  wire  loop  for  plugging,     d.  Polypus   snare,     e  and  /.  Extemporized 
tracheal  auc^sthetizing  apparatus. 

the  tumor  by  aid  of  the  finger.  The  loop  is  tightened  and  the  growth 
severed.  The  growth  may  be  strangulated  by  means  of  intertwined  loops 
placed  around  the  pedicle  as  indicated  in  Fig.  834.  The  greater  length  of 
time  required  and  the  offensive  odors  that  often  attend  the  removal  do  not 
commend  the  method. 


OPERATIONS   ON  THE  NOSE. 


653 


Fig.  832. — Loop  guided  over  polypus  with  finger. 


The  Removal  of  some  Nasal  and  Naso-pharyngeal  Polypi. —  In  addi- 
tion to  instruments  employed  in  rejiiovai  of  nasal  growths  (Fig.  831) 
there  may  be  also 
required  instruments 
for  ligature  of  ves- 
sels (Fig.  ITS);  tor 
excision  of  the  jaw 
(Fig.  378) ;  chisels 
and  mallet  (Fig.  450), 
and  for  tracheotomy 
and  tracheal  ana?s- 
thesia  (pages  682 
and  652).  An  abun- 
dance of  forcipres- 
sure,  ligatures,  anti- 
septic wipers  (Fig. 
73),  and  gauze,  should 
be  provided.  If  the  growth  be  fibrous  and  not  amenable  to  treatment  by  the 
previous  methods,  or  be  of  naso-pharyngeal  origin,  it  can  then  be  exposed 

either  by  way  of  the  nasal  pala- 
tine or  maxillary  routes.  The 
nasal  route  is  best  suited  to  the 
removal    of    growths    limited    to 


the  nasal  cavity.  They  may  be 
reached  by  turning  the  carti- 
laginous part  of  the  nose  aside 
(Desprez). 

Tlie  Operation. — Locate  the 
free  margin  of  the  nasal  bone; 
divide  the  skin  parallel  with 
this  margin  from  the  middle 
line  of  the  nose  down  to  the 
junction  of  the  cheek  and  nostril,  and  thence  cut  downward,  ending 
in  the  nasal  orifice  of  the  oppo- 
site side;  separate  the  cartilagi- 
nous from  the  bony  part  of  the 
nose  by  means  of  scissors,  and  the 
inferior  attachment  of  the  septum 
for  the  proper  distance  by  the  same 
means.  The  end  of  the  nose  is 
freed  and  turned  to  the  opposite 
side,  and,  if  additional  space  be 
required,  the  turbinated  bones  are 
removed.  After  removal  of  the 
growth,  the  end  of  the  nose  is  re- 
placed and  united  with  sutures  to  .„  „„,  .  ,•  ..  .  ,  ^ 
I,      -,.    .  ^    ^  .       ,  Pig.  834. — Apphcation  of  loops  for  tying 

the  divided  borders.  pedicle 


Fig.  833. — Double  cannula  in  position. 


654 


OPERATIVE  SURGERY. 


Chassaignac's  Method. — Chassaignac  carried  an  incision  from  near  the 
inner  canthus  of  one  eye  directly  across  the  root  of  the  nose  to  a  point  cor- 
responding to  that  of  starting,  thence  downward  along  the  outer  side  of  the 
nose  through  the  alar  groove  across  close  beneath  the  end  of  the  nose  to  the 


V 


Fig.  835. — Chassaignae's  method. 
The  incision. 


Fig.  836. — Chassaignae's  method. 
Flap  turned  aside. 


opposite  ala  (Fig.  835).  He  divided  the  bones  in  a  line  corresponding  with 
the  incision  of  the  soft  parts,  also  the  septum,  and  turned  the  nose  to  the 
opposite  side,  thus  exposing  freely  the  nasal  cavity  (Fig.  836). 

After  the  removal  of  the  growths  the  parts  are  restored  to  their  normal 
position  and  the  edges  of  the  wound  united.  If  this  method  he  not  deemed 
advisable,  the  nose  can  be  turjied  dowiiward  by  making  a  U-shaped  incision 
down  to  the  bone,  the  convex  portion  of  which  shall  cross  the  root  of  the 
nose  between  the  eyes,  while  the  arms  extend  downward  at  each  side  of  the 
nose  to  the  outer  borders  of  the  alse  (Oilier)  (Fig.  837,  a).     The  bones  are 

then  sawed  through  in  the  line  of  the  incision,  the 
septum  liberated  at  their  under  surface,  and  the 
nose  turned  downward,  so  as  to  expose  the  interior 
of  the  nasal  cavity  to  observation  and  manipula- 
tion. If  the  growth  be  a  large  one  and  greater 
space  be  necessary,  the  incision  can  be  modified 
(Fig.  843,  a),  as  shown  by  the  dotted  line,  and  the 
bones  lying  in  its  course  sawed  through,  as  be- 
fore described,  care  being  taken  to  avoid  the 
roots  of  the  teeth.  After  the  removal  of  the 
growth  the  parts  are  replaced  and  confined  in 
position  by  sutures,  dressings,  etc.  Naso-pharyn- 
geal  polypi  can  sometimes  be  removed  by  this 
method. 

In  1873  Eouge  described  the  following  method 
applicable  to  the  removal  of  diseased  bone,  obstinate  polypi,  and  even  small 
naso-pharyngeal  growths  when  located  well  in  front : 


Pig.  837. — a.  Ollier's  method. 
b.  Lawrence's  method. 


OPERATIONS  ON  THE  NOSE. 


655 


Rouge's  Method. — Willi  the  patient's  head  turned  to  one  side  and  the 
upper  lip  drawn  forcibly  upward  by  an  assistant, the  surgeon  carries  a  curved 
scissors  close  to  the  bone  through  the  space 
lying  between  the  bicuspid  teeth  of  the  re- 
spective sides,  severing  the  soft  parts  up, 
to  and  opposite  the  nasal  bones.  At  the 
same  time  the  cartilaginous  septum  is  de- 
tached from  the  nasal  spine,  thus  permit- 
ting the  end  of  the  nose  to  be  turned  up- 
ward toward  the  forehead,  thereby  exposing 
the  anterior  nares  to  free  examination  (Fig. 
838).  After  removal  of  the  growth,  the 
parts  are  restored  to  their  normal  place  and 
held  there  by  careful  bandaging. 

Langenbech's  Method  (Fig.  839,  a). — 
Make  an  incision  from  near  to  the  center  of 
the  root  of  the  nose  obliquely  downv/ard 
and  outward  on  the  outer  side  of  the  nose 
and  cheek  to  a  point  external  to  the  ala 
nasi.  Separate  the  upper  border  of  the  flap 
a  short  distance,  leaving  the  periosteum;  sever  the  alar  cartilage  from 
the  nasal  bone,  and  with  bone  nippers  sever  the  nasal  bone  from  its  fellow. 
Also  in  the  same  manner  divide  the  nasal  process  of  the  superior  maxilla 
at  its  base  through  to  the  margin  of  the  orbit  (Fig.  840).  The  entire  upper 
part  of  the  nasal  cavity  can  then  be  exposed  by  raising  upward  the  quadri- 
lateral piece  of  bone  thus  formed  of  both  the  nasal  bone  and  process 


Fig.  838. — Rouge's  method. 


k/'^^T^ 


Fig.  839. — a    Lan<?enl)eck's  method. 
1}    BoeckcTb  method. 


Fig.  840. — Langenbeck's  method. 
Flap  turned  aside. 


together.  After  the  tumor  is  removed  the  bone  flap  can  be  returned  and 
fastened  in  its  proper  position. 

Laivrence's  Method  (Fig.  837,  1)). — From  a  point  just  internal  to  the 
lachrymal  sac,  make  an  incision  along  each  side  of  the  nose  to  the  junction 
of  the  ala  with  the  lip.  Sever  the  nasal  bones  and  the  nasal  processes  of 
the  superior  maxilla;  with  bone  forceps,  thus  opening  into  the  nasal  cavity. 
Divide  the  septum  and  turn  the  nose  upward. 

The  Comments. — Eouge's  method  leaves  no  scar  and  the  parts  are  read- 
ily adjusted  without  sutures.     The  nose,  however,  should  be  supported  in 


656 


OPERATIVE  SURGERY. 


proper  shape  until  union  takes  place.  The  amount  of  room  provided  by 
these  operations  is  limited,  therefore  a  careful  determination  of  the  con- 
nections of  the  growth  must  be  made  before  operation,  to  avoid  unwise  or 
needless  mutilation. 

The  palatine  route  is  suited  for  the  treatment  of  more  difficult  cases 
than  is  the  nasal  one.  Naso-pharyngeal  as  well  as  nasal  growths  are  ap- 
proachable through  this  channel  of  procedure. 

Nelaton's  Method  (Fig.  841,  a). — Make  an  incision  in  the  median  line 
through  the  uvula  and  soft  palate  down  to  the  bone  (a) ;  continue  it  forward 
along  the  posterior  half  of  the  hard  palate;  two  other  incisions,  one  on 
either  side,  are  now  carried  obliquely  outward  from  the  anterior  extremity 

of  the  first  to  the  respec- 
tive alveolar  processes ;  these 
flaps,  including  the  perios- 
teum, are  reflected  outward 
with  a  rugine ;  the  hard  pal- 
ate is  perforated  and  cut 
away;  the  periosteum  and 
mucous  membrane  of  the 
floor  of  the  nose  are  turned 
aside,  the  septum  is  removed 
if  necessary,  the  tumor  ex- 
posed to  view  and  excised. 
The  periosteal  flap  of  the 
hard  palate  should  be  re- 
turned to  the  normal  posi- 
tion and  stitched  in  the  usual 
manner.  The  cut  through 
the  soft  palate  can  be  joined 
then  or  subsequently,  accord- 
ingly as  the  operator  desires. 
If  the  growth  be  a  small  one, 
but  one  side  of  the  hard  pal- 
b.  Chalot's  method,  ate  need  be  attacked. 

Chalofs  Method. — Divide 
the  gingivo-labial  fold  and  separate  the  upper  lip  from  the  bone  at  a  point 
corresponding  to  the  anterior  nasal  spine,  thus  opening  into  the  nasal 
fossae  in  front.  Draw  the  canine  teeth,  open  the  mouth  widely,  and  make 
an  incision  down  upon  the  under  surface  of  the  hard  palate  at  either  side 
close  to  the  alveolus,  beginning  at  the  empty  socket  of  the  canine  tooth, 
and  terminating  at  the  posterior  border  of  the  bone  (Fig.  841,  h,  h) ;  divide 
the  alveolus  and  hard  palate  at  either  side  in  the  line  of  incision  with 
chisel  and  mallet;  separate  the  bony  flap  thus  formed  from  its  connec- 
tions with  the  vomer  and  nasal  mucous  membrane;  displace  it  downward 
and  backward  into  the  mouth,  the  velum  acting  as  a  hinge;  remove  the 
growth;  restore  and  fasten  the  bone  flap  in  place  with  wire  sutures.  This 
procedure  is  ingenious  and  effective  except  when  the  growths  are  large  and 


Fig.  841. — a.  Nelaton's  method. 


OPERATIONS  ON  THE  NOSE.  657 

located  at  the  vault  of  the  pharynx.  The  degree  of  haemorrhage  in  this 
operation  is  an  important  item,  and  suggests  the  advisability  of  tracheotomy 
and  a  pharyngeal  tampon  as  wise  preliminary  measures,  especially  as  the 
presence  of  the  bone  flap  will  impede  the  manipulations  of  the  surgeon. 

AnnandaWs  Method. — Expose  the  anterior  nares  as  advised  by  Rouge 
(page  65.!));  divide  the  bony  septum  at  its  connections  Avith  the  maxillae; 
open  the  mouth  widely  and  make  an  incision  in  the  median  line  of  the  hard 
palate  down  to  the  bone ;  remove  a  middle  incisor  if  need  be,  and  divide  the 
alveolus  and  hard  palate  in  the  median  line  with  a  small  saw  introduced 
through  the  nose.  The  soft  palate  is  not  disturbed  unless  the  size  or  position 
of  the  morbid  growth  calls  for  it.  The  maxillse  are  pried  apart  or  drawn 
asunder  with  hooks,  if  required,  carefully  avoiding  displacement  of  the 
nasal  bones  by  severing  their  connections  with  the  nasal  processes  of  the 
superior  maxillae,  if  called  for,  the  tumor  is  exposed  and  removed  with 
forceps,  scissors,  scoops,  etc.  Thorough  disinfection,  and  packing  with 
antiseptic  gauze  follows  the  removal,  succeeded  by  restoration  and  wiring  of 
the  bones  in  the  proper  position.  The  soft  palate  should  be  closed  at  the 
same  time  if  the  condition  of  the  patient  does  not  contra-indicate  it.  This 
operation  offers  the  most  room  of  any  by  this  route,  with  no  loss  of  structure 
or  resulting  deformity. 

The  maxillary  route  is  selected  when  the  size  and  nature  of  the  growth 
render  the  preceding  ones  dangerous  on  account  of  the  hindrance  due  to  the 
limited  space  available  for  operation.  A  preliminary  tracheotomy  is  advisable 
if  the  tumor  be  large,  of  broad  origin,  or  unusually  vascular. 

BoeckeVs  Method. — Make  an  incision  down  to  the  bone  from  near  the 
root  of  the  nose  along  its  side  to  the  groove  of  the  nostril  and  cheek,  thence 
in  a  curved  direction  outward  and  backward  on  the  cheek  to  a  point  verti- 
cally below  the  middle  of  the  orbit  (Fig.  839, 1)).  A  second  incision,  begin- 
ning at  the  upper  end  of  the  first,  is  carried  outward  along  the  lower  margin 
of  the  orbit  down  to  the  bone  ;  raise  the  flap  with  the  periosteum  from  the  bone 
with  a  rugine  or  periosteotome,  exposing  the  lower  portion  of  the  nasal  bone 
and  the  entire  width  of  the  nasal  process  of  the  superior  maxilla,  carefully 
avoiding  the  lachrymal  sac  and  the  infra-orbital  nerve ;  define  the  bone  flap 
(Fig.  385,  D)  with  chisel  and  mallet,  commencing  at  the  inner  border  of  the 
infra-orbital  canal  and  going  vertically  downward  to  opposite  the  floor  of 
the  naris,  thence  inward  to  the  naris  itself;  then  divide  the  bone  in  front 
of  the  lachrymal  sac,  the  nasal  process  its  entire  width,  and  finally  cut  down- 
ward and  inward  through  the  lower  portion  of  the  nasal  bone  by  similar 
means,  the  chisel  going  into  the  nose  throughout  the  entire  course  of  the 
bony  incision.  Remove  the  bone  section,  thus  exposing  the  nasal  cavity, 
which  exposure  can  be  still  further  increased  by  removal  of  the  turbinated 
bones.  After  removal  of  the  growth  the  opening  is  closed  by  returning 
and  suturing  in  place  the  periosteal  flap. 

LangenhecFs  Operation. — Make  a  slightly  curved  incision  with  the  con- 
vexity downward,  extending  from  the  ala  of  the  nose  to  the  malar  bone,  and 
thence  as  far  backward  as  the  middle  of  the  zygoma.  A  second  incision  is 
made,  beginning  near  the  center  of  the  root  of  the  nose,  and,  passing  along 


658 


OPERATIVE  SURGERY. 


the  inferior  margin  of  the  orbit,  to  join  the  former  near  the  middle  of  the 
malar  bone  (Fig.  842,  c).  These  incisions  should  extend  down  to  the  bone; 
the  soft  parts,  however,  are  not  to  be  raised,  with  the  exception  of  the  peri- 
osteum of  the  floor  of  the  orbit,  which  should  be  raised  if  the  orbital  plate 
is  to  be  removed.  Separate  the  masseter  muscle  from  the  malar  bone ;  divide 
the  buccal  fascia;  depress  the  inferior  maxilla  and  pass  a  pointed  elevator, 
or  the  finger  if  possible,  into  the  posterior  nares,  carrying  it  by  way  of  the 
lateral  opening  through  the  pterygo-maxillary  fissure  into  the  spheno-maxil- 
lary  fossa,  thence  through  the  spheno-palatine  foramen,  all  of  which  passages 
may  have  been  distended  by  the  morbid  growth.  A  small  keyhole  saw  is 
passed  by  the  same  route,  and  the  superior  maxilla  divided  from  behind  for- 
ward in  the  line  of  the  lower  skin  incision  (Fig.  385,  F,  F).  The  extremity  of 
the  saw  is  covered  by  the  end  of  the  index  tinger  carried  into  the  pharynx 
through  the  mouth,  to  protect  the  tissues  from  being  injured  by  it.  The 
zygomalic  process  of  the  temporal,  frontal  process  of  the  malar,  and  orbital 
plate  of  the  superior  maxilla  are  then  sawed  through  from  behind  forward  to 
the  lachrymal  bone,  the  saw  here  being  made  to  pass  in  its  course  through 
the  spheno-maxillary  fissure.     Or  the  superior  maxilla  can  be  divided  in  the 

line  of  the  superior  incision  of  the  soft  parts, 
thus  leaving  the  orbital  plate  intact.  The 
osteo-cutaneous  flap  is  now  raised  by  an  ele- 
vator carried  beneath  the  malar  bone  and 
slowly  lifted  upward  and  inward  toward  the 
nose,  the  bones  and  soft  parts  of  which  form 
a  hinge  to  the  flap  at  that  side.  If  the  saw 
can  not  be  passed  into  the  posterior  nasal 
cavity  even  by  the  aid  of  a  grooved  director, 
the  lips  of  the  incision  of  the  soft  parts 
may  be  drawn  asunder,  and  the  bone  sawed 
from  without  inward  and  before  backward. 

The  Comments. — The  operation  is  usually 
attended  by  quite  severe  haemorrhage,  which, 
however,  can  be  controlled  readily  by  pressure 
and  an  occasional  ligature.  After  the  re- 
moval of  the  growth,  the  parts  are  adjusted 
&.   and  confined  in  position  by  sutures,  etc.     If 


Pig.  842.— a.  Ollier's 
Guerin's  incisions 
beck's  incision. 


c.  Langen- 


the  growth  to  be  removed  be  a  large  and  vas- 
cular one,  a  preliminary  tracheotomy  should 
be  done.  If  it  be  malignant  or  very  vascular,  and  have  a  large  attachment,  we 
deem  it  a  wise  precaution  to  tie  both  external  carotids  prior  to  removal.  The 
dangers  from  haemorrhage  will  be  lessened  by  this  measure,  and,  moreover, 
the  diminished  vascularity  of  the  parts  will  hinder  the  redevelopment  of  the 
growth.  Dawbarn  practices  the  removal  of  these  vessels  and  for  similar 
reasons. 

The  division  of  the  bones  can  be  readily  and  advantageously  done  with 
an  osteotome  and  mallet  (Fig.  450),  especially  when  the  spaces  at  the  back 
of  the  jaw  are  not  sufficiently  distended  by  the  growth  to  permit  a  wise  use 


OPERATIONS  ON  THE  NOSE. 


659 


of  the  saw.  The  difficulty  of  raising  the  flap  and  of  returning  and  properly 
adjusting  it,  thereby  incurring  the  dangers  of  necrosis,  with  consequent  sepsis 
and  non-union,  are  objectionable  features  of  the  measure. 

The  IlesuUs. — The  rate  of  mortality  from  this  method  is  less  than 
twenty-five  per  cent,  and  depends  more  on  the  dangers  arising  from  the 
removal  of  the  growth  than  those  the  result  of  the  steps  necessary  to  reach 
it.  The  mortality  is  greater  when  the  operation  is  done  through  the  hard 
palate  than  when  performed  by  means  of  the  displacement  of  the  upper  jaw. 

Guerin''s  Method. — Make  an  incision  along  the  facial  line  from  the  ala 
of  the  nose  to  the  angle  of  the  mouth ;  dissect  up  the  soft  parts,  opening 
the  nostril,  and  bare  the  malar  process  of  the  superior  maxilla;  introduce 
a  saw  or  chisel  into  the  nose  and  divide  entirely  the  maxilla  horizontally 
backward  below  the  infraorbital  canal ;  separate,  through  the  mouth,  the  soft 
from  the  hard  palate  with  a  scalpel ;  remove  a  middle  incisor  tooth  and 
divide  the  hard  palate  in  the  median  line  with  a  saw  or  chisel.  The  frag- 
ment is  then  taken  away  with  lion-jaw  forceps. 

The  Remarks. — This  operation  is  an  excellent  one  so  far  as  deformity  is 
concerned,  and  can  be  practiced  even  without  division  of  the  lip.  The 
employment  of  an  artificial  appliance  to  the  roof 
of  the  mouth  will  remedy  the  resulting  defect  in 
speech  (page  373). 

Kocher's  Method. — Place  the  patient  in 
Kose's  position  and  divide  the  upper  lip  from 
above  downward;  sever  transversely  down  to  the 
bone  the  reflection  of  the  mucous  membrane 
above  the  alveolar  process;  with  a  chisel  cut 
through  obliquely  on  a  level  with  the  nasal  proc- 
ess the  superior  maxillary  bones  (Fig.  8-1:3) ; 
divide  the  alveolar  process  and  the  hard  palate 
in  the  median  line  and  draw  the  bones  apart  with 
hooks;  incise  the  m^icous  membrane  of  the  floor 
of  the  nasal  fossa  close  to  the  septum,  and 
push  the  vomer  to  the  opposite  side,  thus  exposing  freely  to  observation  the 
naso-pharyngeal  space.  After  removal  of  the  tumor,  restore  and  fasten  the 
parts  in  position  with  wire  or  an  interdental  splint. 

Cheever's  Method. — In  Cheever's  case  both  superior  maxilla  were  re- 
moved, owing  to  the  large  size  and  central  situation  of  the  growth.  Cheever 
made  an  incision  from  near  the  inner  canthus  on  each  side  of  the  nose, 
downward  along  the  natural  furrow,  around  the  ala?  to  the  median  line  of  the 
lip,  which  he  divided.  These  flaps  were  reflected  upward  and  outward  as  far 
as  the  malar  prominences,  and  the  bodj^  of  each  superior  maxilla  was  sawed 
from  behind  forward  to  the  middle  meatus  of  the  nose ;  the  septum  and  vomer 
were  cut  with  scissors  ;  the  jaws  were  then  depressed  and  the  tumor  removed, 
after  which  the  bones  were  replaced  and  wired  in  position.  The  loss  of 
l)lood  was  not  great,  but  the  patient  died  on  the  fifth  day  from  exhaustion. 

The  General  Coinmoits. — The  excision  of  the  entire  upper  jaw  may  be 
practiced  for  the  removal  of  neoplasms,  or  only  the  portion  below  the  line 


Fig.  843. — Kocher's  method. 


660  '  OPERATIVE   SURGERY. 

of  the  orbital  floor  may  be  removed.  The  superior  maxilla  can  be  raised 
and  turned  outward  on  a  hinge  formed  by  the  zygomatic  process  of  the 
malar  bone  and  the  contiguous  soft  parts  by  dividing  the  bone  in  the  line  of 
Ferguson- Webber's  incision  (Fig.  380,  h,  b'),  the  upper  portion  of  which,  for 
this  purpose,  should  be  extended  to  the  malar  bone.  The  maxillae  are  sep- 
arated by  sawing  through  the  hard  palate  and  alveolar  process,  and  the  nasal 
bone  is  disconnected  from  the  superior  maxilla  by  severing  its  connections 
with  bone  forceps.  The  osteocutaneous  flap  can  then  be  raised  and  swung 
outward.  If  necessary,  the  soft  palate  may  be  divided.  After  the  removal 
of  the  growth,  the  parts,  including  the  soft  palate,  are  adjusted  and  joined 
by  sutures. 

With  the  view  of  avoiding  as  far  as  possible  the  division  of  the  terminal 
filaments  of  the  superior  dental  nerve,  and  obviating  the  loss  of  function 
incident  thereto,  Langenbeck  recommended  that  a  curved  incision  be  made, 
crossing  the  cheek  about  midway  between  the  angle  of  the  mouth  and  the 
lower  border  of  the  orbit,  beginning  near  the  lower  end  of  the  nasal  bone 
and  extending  downward  and  outward  and  then  upward,  so  as  to  avoid 
Steno's  duct.  The  flaps  are  dissected  from  the  superior  maxilla,  which  is 
removed  through  the  opening  made  in  the  soft  parts.  If  the  whole  bone  is 
to  be  excised,  the  integrity  of  the  superior  maxillary  nerve  can  be  still  fur- 
ther preserved  by  removing  it  in  advance  from  the  infra-orbital  groove  by 
the  aid  of  a  fine,  sharp  chisel. 

The  removal  of  a  growth  of  any  great  size  from  the  posterior  nares  or 
pharynx,  especially  the  latter,  will  be  attended,  if  its  attachment  be  exten- 
sive, by  the  entrance  of  a  large  amount  of  blood  into  the  pharynx  and 
trachea ;  it  is  therefore  wise  to  do  a  preliminary  tracheotomy,  so  that  the 
lower  extremity  of  the  pharynx  may  be  closed  by  sponges  or  otherwise 
tamponed.  If  the  shoulders  be  elevated  and  the  head  allowed  to  fall  far 
backward,  the  blood  can  be  removed  from  the  dependent  portion  of  the 
pharynx  as  fast  as  it  collects ;  this  position,  however,  impedes  respiration  by 
overextending  the  muscles  that  act  on  the  os  hyoides.  If  a  preliminary 
tracheotomy  be  done,  the  anaesthetic  must  be  administered  through  the 
tube.  The  apparatus  devised  for  this  purpose  by  Trendelenburg  (Fig.  877) 
may  be  used  entire,  or  only  the  inhaling  portion  attached  to  the  ordinary 
tracheotomy  tube  can  be  employed ;  the  latter  plan  is  generally  to  be  pre- 
ferred, since  the  rubber  tampon  attached  to  this  tube  often  causes  bronchial 
irritation  when  inflated ;  moreover,  if  it  become  ruptured  during  the 
course  of  an  operation,  or  be  imperfectly  distended,  blood  may  enter  the 
trachea  unawares. 

Extemporized  substitutes  for  this  purpose  can  be  provided  if  a  rubber 
tube  of  suitable  size  and  length  be  attached  by  one  extremity  to  the  trache- 
otomy tube,  and  the  other  be  inserted  loosely  into  the  bottom  of  an  empty 
quarter-pound  ether  can  and  fastened  there,  and  a  sponge  be  introduced 
into  the  can  and  kept  moistened  with  ether  (Fig.  831,  /).  The  anaesthesia 
thus  produced  will  be  eminently  satisfactory  and  the  outlay  nominal.  In 
the  absence  of  the  ether  can,  pass  the  end  of  the  rubber  tube  through  a 
tightly  fitting  opening  in  the  center  of  a  pasteboard  diaphragm  properly 


OPERATIONS   ON   TIIK   NOSE.  061 

adjusted  to  a  glass  tumbler  in  the  bottom  of  which  rests  a  sponge  mois- 
tened with  ether  (Fig.  831,  e). 

Tlic  choice  of  operation  is  regulated  largely  indeed  by  the  size,  situa- 
tion, attachments,  vascularity,  and  nature  of  the  growth.  If  the  growth  be 
comparatively  small,  with  a  well-defined  pedicle,  and  accessible  through  the 
nose,  this  channel  may  be  adopted.  Annandale's,  Boeekel's,  and  Guerin's 
methods  are  suited  to  tlic  treatment  of  large  naso-pharyngeal  growths. 
Langenbeck's  method  is  ([uite  commonly  practiced,  and  is  an  admirable 
one,  especially  when  the  naso-})harynx  is  much  distended  by  the  growth. 
The  removal  entirely  or  the  swinging  outward  or  inward  of  the  superior 
maxilla,  after  free  incision,  affords  a  fine  exposure  of  the  naso-pharynx, 
especially  the  removal  of  the  bone.  In  one  instance  the  author  practiced 
removal  with  great  operative  satisfaction,  and  followed  with  but  slight 
cosmetic  defect. 

The  after-treatment  is  essentially  that  for  removal  of  the  jaw  (page  372). 

The  Results. — About  twenty-five  or  thirty  per  cent  die  from  the  oper- 
ation. Here,  as  in  excision  of  the  jaw  for  other  reasons,  septicaemia,  etc., 
claim  a  share  of  the  victims.  According  to  Lincoln,  twenty  per  cent  die 
from  the  operation,  and  in  about  tliirty-six  per  cent  the  disease  returns 
within  twelve  months  after  the  operation.  We  are  disposed  to  regard  the 
latter  figures  as  having  a  decidedly  optimistic  expression. 

Deviation  of  the  Septum  Nasi. — It  not  infrequently  occurs  that  both 
the  bony  and  cartilaginous  portions  of  the  septum  are  deflected  to  such  an 
extent  as  to  seriously  interfere  with  breathing  through  the  nose  during 
attacks  of  eoryza,  and  likewise  to  impart  a  distinct  nasal  twang  to  the  voice. 
This  deformity  may  or  may  not  be  associated  with  external  modifications 
of  the  nasal  symmetry.  In  either  case  the  indications  remain  the  same :  to 
overcome  the  deformity  and  to  maintain  the  corrected  relations  of  the  parts 
until  recovery  takes  place. 

Tlie  Operation. — The  deformity  can  be  overcome  by  grasping  the  abnor- 
mal septum  between  the  blades  of  a  forceps  especially  designed  for  the  purpose 
(Fig.  845,  /),  which  are  thrust  into  the  anterior  nares  and 
closed  upon  the  deformed  sejitum  and  held  for  a  few  moments 
with  sufficient  firmness  to  press  its  irregularities  into  a  nor- 
mal position.  This  resistance  is  still  further  overcome  by  cau- 
tiously turning  the  forceps  from  side  to  side  on  its  long  axis. 
The  pressure  exerts  a  crushing  and  compressing  influence  on 
the  septum,  permitting  of  its  being  pressed  into  a  normal  po- 
sition. The  retentive  apparatus  is  a  specially  constructed 
clamp  (Fig.  844),  which  is  screwed  into  position  while  grasp- 
ing the  septum.  This  instrument  retains  the  part  thus  rec- 
tified until  the  reparative  processes  necessary  to  permanency 
shall  have  taken  place.     The  clamp  mav  remain  in  position 

'Pin   S44 

two  or  three  days,  not  tightly  screwed,  for  this  would  cause    Adams's  clamp 
ulceration,  but  closely  enough  to  exert  a  gradual  controlling 
influence  on  the  structure.     This  indication  can  likewise  be  well  met  by 
introducing  into  each  nostril  rubber  tubes  of  proper  size  and  length,  sur- 


662 


OPERATIVE  SURGERY. 


rounded  by  oiled  lint.  After  three  or  four  days  either  of  tlie  preceding  ap- 
pliances should  be  replaced  by  splints  (Fig.  845,  e,  li,  d),  which  are  pushed 
into  each  nostril  and  worn  at  night  only.  This  treatment  is  annoying  and 
even  attended  by  positive  discomfort,  but  the  good  result  will  amply  repay 
the  patient  for  the  infliction  incurred.  Other  operations  are  recommended, 
such  as  the  removal  of  the  inferior  turbinated  bone  on  the  side  of  the  deflec- 
tion ;  or  punching  the  septum  to  establish  a  communication  between  the 
closed  and  the  unclosed  nostrils.  Neither  of  these  acts  rectify  the  deformity, 
and  both  are  open  to  objections,  the  former  of  a  physiological,  the  latter 
of  a  mechanical  nature.  The  removal  of  the  projecting  portion  of  the 
cartilage  and  its  mucous  membrane  is  likewise  commended.  The  taking  away 
of  the   deformed  septum,  together  with  a  portion  of  the  superior  maxilla 


Fig.  845. — Instruments  employed  in  treatment  of  deviation  of  the  nasal  septum. 
a.  Douglass's  knives,     l.  Mial's  and  Curtis's  saws.     c.  Bosworth's  saw.     e,  Ti,  d.  Asch's, 
McKernon's,  and  Douglass's  nasal  splints,    f.  Asch's  scissors  and  septum  compressor. 
i.  Douglass's  perforator,    g.  Elevator. 

(Post),  accomplished  by  separating  the  side  of  the  nose  from  the  cheek, 
and  turning  the  nose  over,  thus  gaining  access  to  the  obstruction,  con- 
stitutes an  operation  whose  severity  is  out  of  proportion  to  that  of  the 
primary  difficulty,  and  may  be  followed  by  an  unsightly  scar.  It  is  recom- 
mended also  that  the  meatus  be  burred  out  (Wagner)  by  means  of  the 
dental  engine.  The  reported  results  certainly  give  strong  testimony  in 
favor  of  this  proposition.  The  deformed  portion  of  the  septum  may  be 
sawed  off  on  a  plane  conforming  to  that  of  the  remaining  portion  by  first 
applying  a  strong  solution  of  cocaine  to  it,  then  removing  the  deformity 


OPERATIONS  ON  THE  (ESOPHAGUS.  663 

with  a  narrow,  fine  saw  (Fig.  845,  c)  constructed  especially  for  the  purpose. 
This  ]i]an  is  practiced  hy  Boswortli,  and  it  afjpcars  to  he  prei'erahle  to 
hurring  or  punching  the  septum. 

THE    OPERATIONS    ON   THE    (ESOPHAGUS. 

The  nature  of  the  functions  and  the  important  intimate  anatomical 
environments  of  the  cesophagas  contribute  greatly,  indeed,  to  the  difficulty 
of  treatment  of  this  passage,  and  also  favor  the  development  in  it  of 
obstructive  changes  of  grave  import.  The  anatomical  relations  of  this  tube 
should  be  carefully  considered,  and  the  possibilities  of  a  cure  cautiously 
weighed,  before  active  interference  is  begun.  Otherwise,  what  appears  to 
be  a  simple  matter  and  quickly  curable  may  by  illogical  eifort  become  sud- 
denly of  the  greatest  import  and  of  irremediable  nature. 

Tlie  Anatomical  Points. — The  oesophagus  begins  at  the  cricoid  cartilage 
on  a  level  with  the  sixth  cervical  vertebra.  It  lies  in  the  median  line  at  the 
beginning,  but  bears  off  half  an  inch  toward  the  left  in  the  cervical  region ; 
then  returns  to  the  median  line  at  the  fifth  dorsal  vertebra  and  again  tends 
slightly  toward  the  left  as  it  passes  through  the  diaphragm,  terminating 
opposite  the  ninth  dorsal  spine  behind,  which  corresponds  to  the  left  seventh 
chondro-sternal  junction  in  front.  In  a  sagittal  direction  the  oesophagus 
corresponds  to  the  curves  of  the  portions  of  the  spinal  column  with  which 
it  is  associated.  The  average  diameter  is  about  four  fifths  of  an  inch  ;  the 
smallest — a  little  more  than  half  an  inch — is  wisely  placed  at  the  beginning 
of  the  tube  ;  the  second  narrowing  is  opposite  the  fourth  dorsal  vertebrae, 
the  third  at  the  diaphragm.  The  narrowest  parts  can  be  dilated  to  three 
fourths  of  an  inch  and  the  remainder  to  an  inch  and  a  half  in  the  dead 
subject.  The  transverse  diameter  exceeds  the  antero-posterior.  Since  these 
measurements  are  based  on  post-mortem  experiments,  they  can  be  regarded 
only  as  indicating  rather  than  establishing  the  limits  of  dilatation,  a  fact 
which  is  emphasized  frequently  in  the  living  by  the  ready  passage  along  the 
oesophagus  into  the  stomach  of  articles  of  much  greater  dimensions  than  are 
those  assigned  to  the  passage  itself.  Ogstan  considers  that  food  traverses 
the  normal  oesophagus  in  about  four  seconds.  Cannon  and  Moser  deter- 
mined that  fluids  "  are  propelled  deep  into  the  oesophagus ' '  at  the  rate  of 
seven  feet  per  second.  With  the  finger  on  the  larynx  and  the  ear  at  the 
back,  swallowing  time  may  be  told. 

The  consultation  of  a  text-book  on  anatomy  will  promptly  suggest  those 
important  relations  which,  in  the  presence  of  disease  or  invasion,  invite  dis- 
aster if  unwisely  disturbed.  The  trachea,  carotid  vessels,  aorta,  pericardium, 
left  bronchus  and  mediastinum,  are  of  special  importance  in  this  regard. 

Foreign  Bodies  in  the  CEsophagus. — The  nature,  shape,  and  size  of  the 
foreign  body,  together  with  the  situation  and  time  of  impaction  and  the 
symptoms,  must  be  ascertained  with  deliberation  if  the  condition  of  the 
patient  will  permit.  Foreign  bodies  are  arrested  commonly  at  the  narrowest 
part  of  the  a^sophagus,  therefore,  usually  at  the  beginning.  At  this  situa- 
tion the  foreign  body  can  be  easily  touched  with  a  probang  and  often  with 
the  index  finger,  although  not  without  causing  the  patient  distress  if  con- 


664 


OPERATIVE   SURGERY. 


sciousness  be  present.  Careful  examination  of  the  left  side  of  the  neck,  be- 
hind the  cricoid  cartilage,  will  often  disclose  the  presence  of  the  obstruction. 
When  situated  lower  down,  the  probang  and  bougie  will  establish  the  fact 
(Fig.  846).     After  failure  of  the  simpler  means  of  removal — i.  e.,  external 


J'lf;.  840. — Instriunents  employed  in  removal  of  foreign  bodies  from  tt'sophagus. 
a.  Bristle  probang,  opened  and  closed,     b.  ('(An  catcher  and  sponge  probang,  whalebone. 
c.    Roe's  flexible  coin  catcher,      d.    Tiemann's  flexible   cork-catching   forceps,      e. 
Cu.sco's  throat  forceps,    /and  ff.  Curved  throat  forceps.     Curved  forceps  of  different 
patterns  may  be  employed. 

rriani)jul;itio)i,  omesis,  etc. — the  obstruction  is  usually  removed  at  the  higher 
situation  with  throat  forceps  designed  for  the  purpose  (Fig.  846,  e),  or  by 
the  bucket  probang  (&),  or  by  a  loop  of  wire,  or  other  simple  devices  of  this 
character.    However,  if  the  obstruction  have  been  lodged  here  for  some  time. 


OPERATIONS  ON  THE  OESOPHAGUS. 


665 


consequent  swelling  of  the  soft  parts,  or  irregularities  of  the  foreign  body, 
may  render  removal  by  way  of  the  mouth  impossible.  The  same  may  be  said 
also  of  foreign  bodies  located  elsewhere  in  the  tube.  The  bristle  and  the 
sponge  probang  (Fig.  846,  a,  h)  are  the  common  implements  for  removal 
under  these  circumstances.     The  X-ray  is  very  useful  in  these  cases. 

TJie  Bemarks. — It  is  seldom  indeed  that  a  foreign  body  causes  complete 
occlusion  of  the  oesophagus.  Those  too  large  to  enter  it  encroach  not  infre- 
quently on  the  larynx  and  cause  death  from  suffocation.  The  lodgment  of 
an  article  near  the  cardia  is  specially  dangerous  because  of  the  proximity  of 
the  heart,  great  vessels,  and  pleura.  While  all  bodies,  irrespective  of  their 
physical  characteristics,  lodge  most  frequently  at  the  established  narrowings 
of  the  oesophagus,  irregular  and  sharp  ones  may  lodge  between  these  points, 
but  round  and  flat  ones  do  not.  External  manipulation  for  removal  is 
applicable  only  to  the  obstructions  located  in  the  cervical  portion,  and  should 
not  be  practiced  in  the  event  of  firm  impactiou  or  when  marked  asperities 
characterize  the  obstructing  agent. 

The  Introduction  into  the  (Esophagus  of  Instruments.— The  introduction 
of  an  instrument  into  the  ossophugus  is  usually  a  simple  procedure. 

A  Method  of  Introduction  of  a  Stomach  Tube. — Place  the  patient  in  a 
good  light  while  in  a  cbair  or  sitting  up  in  bed  ;  tip  the  head  backward  and 
give  it  in  charge  of  an 
assistant ;  gag  the  mouth ; 
seize  the  tongue  (guarded 
from  slipping  with  a  dry 
cloth)  with  the  thumb 
and  fingers  and  draw  it 
forward,  thus  advancing 
the  larynx ;  grasp  the  pre- 
viously warmed  and  oil- 
smeared  instrument  light- 
ly in  the  right  hand ;  carry 
the  end  downward  and 
backward  to  the  poste- 
rior wall  of  the  pharynx; 
push  it  along  as  the  pa- 
tient gags,  and  cause  him  to  swallow  as  the  advancing  extremity  engages  in 
the  lower  part  of  the  phar}Tix;  advance  the  instrument  with  gentleness, 
heeding  the  presence  of  spasm  or  other  obstruction,  until  finally  the  instru- 
ment passes  readily  along  the  oesophagus  into  the  stomach. 

Other  Metliods  of  Introduction. — Instead  of  grasping  the  tongue  the 
index  finger  can  be  introduced  as  a  guide  to  the  advancing  instrument,  as  is 
commonly  practiced  in  the  introduction  of  an  oesophageal  bougie,  conducting 
it  safely  over  the  larynx  to  the  posterior  aspect  of  the  pharynx  (Fig.  847). 
Solis-Cohen  recommends  the  drawing  of  the  larynx  forward  with  the  thumb 
and  fingers  applied  without.  The  accomplishment  by  this  method  requires 
the  employment  of  a  firm  and  somewhat  painful  pressure  (except  perhaps  in 
the  presence  of  anaesthesia)  that  is  out  of  proportion  to  the  demands  of  the 
U 


Fig.  847. — Introducing  tube  into  cesophagus. 


QQQ  OPERATIVE  SURGERY. 

case.  The  location  of  the  obstruction  can  be  estimated  by  recalling  the  fact 
that  in  the  average-sized  adult  the  distance  from  the  diaphragmatic  narrow- 
ing of  the  oesophagus  to  the  upper  incisor  teeth  is  about  fourteen  inches 
and  a  half,  and  from  the  aorta  and  from  the  upper  end  of  the  oesophagus  to 
the  same  teeth  is  nine  and  five  and  a  half  inches  respectively.  These  facts 
are  of  immense  importance  as  bearing  on  the  relation  of  the  obstructing 
agent  to  important  organs  and  the  liability  of  serious  complications  from 
the  passage  and  from  the  effects  of  the  means  employed  for  relief. 

The  Precautions. — The  introduction  into  and  passage  along  the  oesopha- 
gus of  a  probang,  bougie,  etc.,  and  the  manipulation  of  the  foreign  body 
should  be  conducted  with  great  care  and  a  minimum  expenditure  of  force, 
otherwise  perforation  will  ensue,  and  especially  is  this  true  in  those  cases 
characterized  by  the  structural  changes  incident  to  disease  and  ulceration  of 
the  walls  of  the  tube.  Avoid  entering  the  larynx  with  the  instrument. 
Coughing  and  continued  spasm  of  the  larynx  with  the  advance  of  the  instru- 
ment indicate  laryngeal  invasion.  The  escape  of  air  through  a  hollow 
instrument  under  these  circumstances  is  diagnostic  of  entry  to  the  larynx. 
Observe  that  the  end  of  the  advancing  instrument  be  not  curved  forward, 
but  instead  that  it  lies  in  contact  with  the  posterior  wall  of  the  pharynx.  A 
cautious  advance  in  the  presence  of  spasm  or  other  source  of  obstruction 
must  always  be  observed.  Eelaxed  and  pouched  states  of  the  pharyngeal  wall, 
notably  at  its  junction  with  the  cesophagus,  oppose  the  progress  of  the  bougie 
not  infrequenlty,  especially  when  the  head  is  not  well  extended.  Deflections 
and  pouches  of  the  CBSophagus  may  interfere  with  the  descent  of  the  bougie, 
and  this  interference  should  not  be  opposed  with  vigor,  for  fear  of  causing 
perforation  of  the  tube.  The  partial  withdrawal  of  the  instrument  and 
the  changing  of  its  course  should  be  practiced  promptly  in  this  instance. 
While  cautious  attempts  made  to  dislodge  an  impacted  body  are  always 
admissible,  still  in  the  instance  of  sharp  and  irregular  impacted  agents  the 
manipulations  should  be  much  more  guarded  in  time  and  method  than  .when 
such  bodies  are  regular  and  smooth.  It  is  much  safer  to  resort  at  once  to  the 
operative  methods  for  extraction  of  the  obstacle  than  to  prolong  and  aggravate 
the  case  by  renewed  efforts  of  removal  or  by  permitting  the  impacted  body 
to  remain,  especially  when  it  is  contiguous  to  important  structures.  Some- 
times the  instrument  becomes  immovably  engaged  to  a  fixed  obstruction, 
requiring  operative  procedure  for  the  liberation  and  extraction  of  both,  and 
the  situation  will  decide  whether  gastrotomy  or  cesophagotomy  shall  be  per- 
formed. 

The  Remarhs. — The  preparation  of  the  walls  of  the  pharynx  for  invasion 
with  instruments,  by  a  weak  solution  of  cocaine,  by  titillation,  the  use  of 
cold,  etc.,  to  arrest  the  spasm,  can  be  practiced  with  discretion.  If  the 
presence  of  a  foreign  body  be  not  noted  with  the  downward  passage  of  the 
bougie,  the  latter  should  be  withdrawn  to  the  upper  end  of  the  tube  and  the 
attempt  repeated,  unless  disclosure  attends  the  withdrawal.  It  should  not 
be  forgotten  that  the  presence  of  the  foreign  body  may  escape  detection, 
and  that  it  may  cause  death  from  perforation  of  the  large  vessels,  heart,  or 
pleura,  without  the  occurrence  of   any  significant  premonitory  symptoms. 


OPERATIONS  ON   THE   (ESOPHAGUS. 


667 


In  children  it  is  wise  to  employ  an  anaesthetic,  as  better  control  of  them  is 
thus  maintained  ;  in  adults  some  assistance  may  be  rendered  by  the  sufferer, 
if  not  anesthetized.  Generally  speaking,  bristle  probangs  and  coin  catchers 
are  used  for  the  extraction  of  smaller,  less  fixed,  and  more  distant  bodies  than 
those  treated  with  the  forceps. 

Many  ingenious  plans  of  action  for  the  removal  of  sjjecial  obstructions 
have  been  devised  and  operated  with  success.  Those  for  the  removal  of 
fish  hooks  and  of  pronged  bodies  swallowed  with  string  attachments  will 
suffice  as  examples  of  successful  attempt,  and  are  fertile  with  suggestion  for 
future  action.  The  line  attached  to  the  hook  is  passed  through  either  a  bullet 
or  some  other  solid  substance,  or  through  a  long,  hollow  bougie.  In  the 
former  instance  the  weisfht  of  the  bullet  and  the  force  of  the  effort  at  swallow- 


FiG.  848. — Instruments  employed  in  (rsophagotomy. 

a.  Scalpels,  b.  Retractors,  c.  Forcipressure.  d.  Mouse-tooth  forceps,  e.  Tongue  for- 
ceps and  forceps  for  extraction  of  foreign  body.  /.  Goodwillie's  mouth  gag.  g.  Curved 
scissors,  h.  Esophageal  bougie.  Drainage  tube,  wipers,  ligatures,  traction  loops,  etc., 
are  essential. 


ing  dislodge  the  hook  ;  in  the  latter,  when  the  lower  end  of  the  bougie  reaches 
the  hook,  it  disengages  it  by  direct  downward  pressure  (i[ackenzie). 

The  swallowing  of  a  sticky  bolus  containing  strong  thread  with  a  string 
attached,  and  the  entangling  of  the  foreign  body  thereby  and  its  withdrawal 


668 


OPERATIVE  SURGERY. 


along  with  the  thread,  often  affords  a  happy  solution  of  the  difficulty 
(Crequy).     A  single  thread  may  be  swallowed  with  fluid  (Dunham). 

If  a  foreign  body  be  immovably  lodged  in  the  oesophagus  it  must  soon  be 
taken  away  through  an  external  incision,  or  a  fatal  result  will  ensue,  due  to 
ulceration  or  extravasation,  or  perhaps  to  starvation  alone. 

The  oesophagus  can  he  entered  for  this  purpose  from  without  through  the 
neck,  the  thorax,  or  the  stomach,  depending  on  the  situation  of  the 
obstruction. 

OEsophagotomy.  - — The  operation  of  cesophagotomy  is  practiced  for  the 
removal  of  obstructions  in  the  cervical  and  upper  dorsal  portions  of  the 
oesophagus,  commonly  caused  by  the  lodgment  of  foreign  bodies. 

The  situation  of  the  foreign  body  in  the  cervical  region  is  usually  deter- 
mined by  the  presence  of  a  prominence  at  the  left  side  below  the  cricoid 
cartilage ;  or,  if  this  be  not  manifest,  the  exact  site  of  lodgment  in  the  canal 
can  be  determined  by  the  introduction  into  it,  through  the  pharynx,  of  a 
good-sized  bulbous  or  other  form  of  bougie  (Fig.  848,  h). 

The  important  surgical  relations  of  the  (esophagus  in  the  cervical  region 
are:  In  front,  with  the  trachea  above  and  with  the  thoracic  duct  and  the 
thyroid  gland  below;  hehind,  with  the  vertebral  column  and  longus-colli 
muscles;  at  the  sides,  especially  the  left,  with  the  common  carotid  and 
inferior  thyroid  arteries  and  thyroid  lobes.  The  recurrent  laryngeal  nerves 
lie  between  the  oesophagus  and  the  trachea  on  the  respective  sides. 

The  Operation  of  Cervical  (Esophagotomy. — After  thorough  aseptic 
measures  employ  an  anassthetic ;  place  the  patient  on  the  back,  with  the  chest 

and  shoulders  elevated  and  the  head  turned 
to  the  opposite  side;  feel  for  the  foreign 
body,  and,  if  it  can  be  located,  make  the 
incision  directly  at  that  point. 

If  the  foreign  body  be  not  discernible 
by  touch,  make  an  incision  about  four 
inches  in  length  on  the  left  side,  between 
the  sterno-mastoid  muscle  and  the  trachea, 
beginning  at  the  upper  border  of  the  thy- 
roid cartilage  (Fig.  849).  The  platysma 
and  fascia  are  divided  on  a  director;  the 
borders  of  the  wound  are  separated,  the 
omo-hyoid  is  drawn  outward,  and  the 
sterno-  and  thyro-hyoid  muscles  inward; 
this  exposes  the  sheath  of  the  carotid, 
which  vessel  is  drawn  outward  and  retained; 
the  lobe  of  the  thyroid  gland  is  raised  and 
drawn  inward ;  the  larynx  is  carefully  out- 
lined, drawn  forward,  and  held  while  the 
location  of  the  foreign  body  is  sought  for ;  if  the  latter  be  not  distinguish- 
able a  bougie  is  introduced  to  mark  the  outline  of  the  tube;  then  raise 
the  wall  with  mouse-tooth  forceps  or  a  tenaculum,  and  open  it  longi- 
tudinally (Fig.  850)  sufficiently  to  admit  a  good-sized  probe,  care  being 


Fig.  849. — (Esophagotomy,  primary- 
incision. 


OPERATIONS  ON  THE  CESOPHAGUS.  069 

taken  to  avoid  tlie  recurrent  laryngeal  nerve.  The  site  of  the  obstruction 
is  located  by  the  probe  and  the  obstruction  is  removed  with  suitable  for- 
ceps, aided  by  manipulation  from  without,  and  facilitated  by  lengthening  the 
oesophageal  incision  if  necessary.  The  opening  in  the  OBSophagus  may  be 
closed  with  two  rows  of  fine  catgut  sutures,  the  inner 
being  applied  to  the  mucous  membrane  only,  if  the 
borders  of  the  incision  have  not  been  injured  by  manipu- 
lation or  impaired  by  the  lodgment  of  the  foreign 
body ;  if,  however,  either  of  these  conditions  be  pres- 
ent, closure  should  not  be  attempted.  In  no  instance 
is  it  wise  to  close  entirely  the  external  incision,  although 
it  may  be  narrowed  by  suturing  the  upper  portion. 
Antiseptic  gauze  is  packed  lightly  in  and  over  the 
wound,  and  confined  in  place  loosely  with  a  gauze 
bandage.     The  aim  must  be  to  keep  the  wound  clean 

and  prevent  extravasation  through  and  inflammation  of  850.— (Esophagot- 

'-      .  .  ^  omy,  final  incision, 

the  cervical  tissues. 

The  Fallacies. — The  foreign  body  may  be  mistaken  for  an  enlarged  gland 
on  external  examination.  The  oesophagus  may  be  confounded  with  the 
longus-colli  muscle  at  first ;  however,  a  moment's  examination  will  serve  to 
dispel  the  doubt.  The  respiratory  movements  of  the  oesophagus,  distending 
and  collapsing  alternately,  are  important  aids  in  determining  its  identity. 
It  must  not  be  forgotten  that  the  swelling,  pain,  and  tenderness  elicited 
by  external  examination  of  the  neck  are  not  necessarily  at  the  exact  site  of 
the  agent  causing  them,  and,  too,  that  exploratory  agents  do  not  always 
indicate  the  presence  of  a  foreign  body.  The  efforts  at  upward  removal  of  a 
foreign  body  that  has  as  yet  caused  no  significant  damage  in  its  downward 
course  are  often  repulsed  by  oesophageal  peristalsis  to  a  degree  that  renders 
removal  upward  unwise  and  perhaps  impossible,  especially  if  the  object  be 
bulky  and  of  irregular  outline. 

The  Reynarks. — If  the  foreign  body  be  not  located  near  the  opening  in 
the  oesophagus,  the  canal  should  be  explored  upward  and  downward  for  its 
detection.  If  below,  it  may  be  at  the  narrow  part  of  the  oesophagus  located 
opposite  the  fourth  dorsal  vertebra,  from  which  point  it  may  be  removed 
with  the  use  of  properly  constructed  forceps.  During  the  operation  all 
bleeding  points  should  be  controlled  promptly.  The  situation  of  the 
inferior  thyroid  artery,  the  anterior  jugular  vein,  and  the  recurrent 
laryngeal  nerve  should  be  clearly  understood,  and  needless  injury  of  them 
avoided.  With  this  object  in  view  and  to  avoid  the  nerve,  the  incision 
into  the  oesophagus  should  be  made  as  far  posteriorly  as  practicable. 
The  opening  in  the  oesophagus  may  be  dilated  by  the  introduction  of  the 
blades  of  curved  dressing  forceps  or  the  lips  pulled  apart  by  traction  loops 
introduced  through  the  borders  of  the  oesophageal  wound.  If  the  obstruct- 
ing agent  be  accessible  and  fixed  in  place  by  its  irregularities  and  projec- 
tions, these,  or  the  object  itself,  can  be  divided  with  bone  forceps  and  after- 
ward easy  removal  accomplished.  Richardson  has  determined  that  the  index 
finger,  when  introduced  into  the  oesophagus  through  a  low  cervical  incision 


6Y0  OPERATIVE  SURGERY. 

(low  cervical  oesophagotomy),  can  reach  the  arch  of  the  aorta  and  in  some 
instances  pass  beneath  it,  also  readily  appose  an  index  finger  introduced  from 
below  through  the  stomach.  The  utilization  of  this  method  of  manipula- 
tion serves  an  important  purpose  in  the  dislodgment  of  impacted  bodies  and 
in  the  dilatation  of  strictures.  Not  infrequently  prompt  union  of  the  bor- 
ders of  the  wound  has  resulted  in  immediate  healing;  but  this  course  of 
action  is  not  to  be  regarded  as  wise  except  in  special  instances,  and  then 
under  close  surveillance.  The  insertion  into  the  bottom  of  the  wound  of  a 
small  drainage  tube  is  desirable  in  cases  in  which  too  free  separation  of  the 
tissue  has  occurred,  and  where  free  discharges  are  anticipated.  If  the  tissues 
at  the  seat  of  the  obstruction  are  already  inflamed,  emphysematous,  etc., 
oesophagotomy  should  be  practiced  at  once  and  the  wound  left  open, 
thoroughly  drained  from  the  bottom,  and  lightly  dressed  with  antiseptic 
materials.  When  the  nutrient  enemata  are  not  retained  or  are  insafficient 
for  proper  nutrition,  a  feeding  tube  should  be  introduced  through  the  mouth 
or  nose  into  the  stomach,  and  be  kept  in  place  or  passed  at  intervals  for  a 
time,  as  circumstances  may  demand.  When  illy  borne  at  these  situa- 
tions, the  introduction  through  the  wound  is  advisable.  Ordinarily  the 
operation  of  cervical  oesophagotomy  is  not  a  perplexing  procedure  ;  but 
when  the  neck  is  short  or  fat,  the  vessels  and  thyroid  gland  enlarged,  the 
detection  and  removal  of  the  foreign  body  difficult,  or  the  patient  is  ex- 
hausted, the  operation  often  taxes  the  patience  and  fortitude  of  the  surgeon. 

The  After-treatment. — Keep  the  patient  in  bed  with  the  head  and 
shoulders  raised,  and  the  head  so  confined  that  the  movements  will  not 
disturb  the  relations  of  the  tissues  of  the  wound.  For  the  first  day  or  so 
nourish  the  patient  by  the  bowel,  after  this  by  means  of  the  stomach  tube, 
until  the  oesophageal  wound  is  healed.  In  the  case  of  a  six-year-old  patient 
operated  on  by  the  author,  fluid  food  was  given  by  the  mouth  after  forty- 
eight  hours,  and  the  escape  from  the  wound,  during  the  act  of  swallowing, 
was  reduced  to  a  minimum  by  gentle  pressure  upon  it,  made  with  a  good- 
sized  pledget  of  aseptic  cotton  batting. 

The  Results. — Eighty-two  cases  are  reported,  of  which  nineteen  died, 
but  from  causes  independent  of  the  operation  in  many  instances.  The  rate 
can  be  placed  at  about  twenty-two  per  cent,  which  will  surely  be  lessened  in 
the  future,  if  the  operation  be  done  as  early  as  it  should  be.  Promptness  of 
operative  action  lessens  the  rate  of  mortality,  as  a  death-rate  of  19.5  per  cent 
follows  operations  made  during  the  first  three  days,  and  32.1  per  cent  after 
that  time. 

Silver  reports  one  hundred  and  sixty-five  instances  of  cervical  oesopha- 
gotomy for  the  removal  of  foreign  bodies  since  1870,  in  which  one  hundred 
and  twenty-seven  recovered  and  twenty-eight  died. 

Foreign  bodies  in  the  intrathoracic  portion  of  the  oesophagus  can  be 
located  with  ease  by  a  probang.  If  situated  at  the  upper  portion,  the  removal 
may  be  accomplished  through  a  low  cervical  oesophagotomy  and  with  the 
use  of  long  curved  forceps.  Inasmuch  as  the  oesophagus  is  quite  narrow 
opposite  the  body  of  the  fourth  dorsal  vertebra,  it  is  fair  to  assume  that  the 
lodgment  will  be  at  this  point.     However,  if  below  this  place,  the  difficulty 


OPERATIONS  ON  THE   (ESOPHAGUS.  671 

of  removal  through  a  cervical  incision  will  be  greatly  increased,  if  not  made 
impossible.  But  inasmuch  as  comparatively  safe  relief  through  thoracotomy 
is  as  yet  quite  improbable,  prompt,  cautious,  and  intelligent  efforts  should  be 
first  emplo3'ed  at  upward  removal,  not  sufficiently  prolonged,  however,  to  im- 
pair the  chances  of  more  rigorous  methods.  Failing  in  these  attempts,  re- 
moval may  yet  be  attained  through  the  'performance  of  thoracotomy  or  gas- 
trotomy.  The  former  method  of  relief  is  fully  described  on  page  12G0  et  seq. 
Gastrotomy. — The  employment  of  gastrotomy  for  the  relief  of  oesophageal 
obstruction  from  any  cause  is  wise  and  usually  effective.  (See  Instruments 
Employed,  page  889.)    The  parachute  snare  is  useful  in  these  cases. 

The  Oi)eration. — An  incision  is  made  in  the  median  line  between  the 
umbilicus  and  ensiform  cartilage  two  or  three  inches  in  length,  the  anterior 
surface  of  the  stomach  is  drawn  forward  and  opened,  the  left  index  finger  or 
the  hand  is  introduced,  and  the  cardiac  orifice  sought  for,  by  directing  the 
index  finger  upward,  backward,  and  to  the  left  opposite  to  a  point  just  outside 
of  the  articulation  of  the  costal  cartilage  of  the  seventh  rib  with  the  sternum. 
From  this  time  forward  either  one  of  two  plans  of  removal  can  be  practiced : 
1.  The  drawing  upward  into  the  mouth  of  the  foreign  body  by  means  of  a 
sponge  (Bull)  or  other  suitable  entangling  agent  connected  to  a  string  intro- 
duced at  the  cardiac  orifice  through  the  opened  stomach,  and  carried  upward 
beside  the  obstacle  and  out  of  the  mouth  by  means  of  a  small  bougie.  2.  By 
dilatation  of  the  cardiac  orifice  and  the  lower  part  of  the  oesophagus  with  the 
index  finger  (Richardson)  or  a  suitable  instrumental  dilator,  and  the  removal 
of  the  foreign  body  downward  by  forceps,  or  by  the  employment  of  the  sponge 
and  string  introduced  in  the  reverse  manner  to  that  already  described. 
Richardson  advises  that  foreign  bodies  located  thirteen  inches  or  more  from 
the  incisor  teeth  be  removed  by  the  latter  plan. 

Tlie  Precautions. — The  removal  of  foreign  bodies  from  the  oesophagus 
through  the  stomach  should  be  conducted  with  great  care  and  infinite 
patience  by  means  of  forceps,  supplemented  with  dilatation  of  the  opening, 
and  downward  pressure  by  way  of  the  mouth,  combined  with  dextrous 
handling  of  the  obstructing  body.  Rapid,  forcible,  and  illogical  attempts 
at  withdrawal  cause  lacerations  and  perforations  of  the  oesophagus,  followed 
by  the  unfortunate  sequels  which  such  procedures  invite. 

TJie  Comments. — The  size  of  the  abdominal  and  of  the  gastric  incision 
is  regulated  by  the  necessity  of  the  case,  which  necessity  should  be  promptly 
recognized  in  order  to  facilitate  the  operation  and  lessen  the  danger.  Be- 
fore the  incision  is  made  into  the  stomach  careful  packing  around  the  organ 
at  the  borders  of  the  abdominal  wound  should  be  practiced  to  obviate  peri- 
toneal infection.  Forcible  manipulations  in  the  extraction  of  foreign  bodies, 
or  in  extended  digital  exploration  of  the  stomach  or  the  oesophagus  carried 
on  through  inadequate  incisions,  are  often  needlessly  prolonged  and  are  harm- 
ful. When  the  size  and  mobility  of  the  stomach  will  permit  it  should  be 
extensively  drawn  through  the  abdominal  opening  before  being  incised  or 
explored  (Fig.  851).  Transverse  openings  into  the  stomach  cause  less  hrem- 
orrhage  than  longitudinal  ones;  but  extensive  longitudinal  incisions  made 
midway  between  the  greater  and  lesser  curvatures  do  not,  for  anatomical 


672 


OPERATIVE  SURGERY. 


reasons^  cause  dangerous  hgemorrhage.  In  digital  and  instrumental  explora- 
tions the  gastric  incisions  are  made  comparatively  small  and  located  so  as  to 
shorten  the  route  to  the  objective  point.  In  digital  exploration  of  the  stom- 
ach it  is  difficult  indeed  sometimes  to  locate  with  the  fingers  the  site  of 


syyM^ 


Fig.  851. — Delivery  of  stomach  and  introduction  of  forceps. 

the  oesophageal  opening,  because  of  its  obliteration  due  to  contraction  of  the 
walls  of  the  stomach,  provoked  no  doubt  by  the  presence  of  the  finger. 
However,  if  the  finger  be  pressed  cautiously  for  a  time  at  the  site  of  the 
opening  relaxation  will  take  place  and  the  end  of  the  finger  will  readily 
enter  the  tube.  Downward  traction  on  the  stomach  attended  with  flexion 
of  the  cervical  and  dorsal  portions  of  the  spine  render  the  cardiac  opening 
more  accessible  to  manipulation.  The  putting  of  the  lesser  curvature  on 
the  stretch  by  downward  traction  on  the  stomach  enables  one  to  readily  pass 
a  bougie  along  the  curvature  into  the  cardiac  opening,  especially  if  the  gastric 
incision  be  located  well  to  the  right. 

Stricture  of  the  (Esophagus. — For  the  purpose  of  consideration,'  stric- 
ture of  the  oesophagus  will  be  classified  as  malignant  and  non- malignant,  and 
although  either  may  be  treated  by  dilatation,  divulsion,  external  or  internal 
division,  or  tuiage,  it  will  appear  that  a  diversity  of  modes  of  treatment 
is  better.  In  the  oesophagus  as  in  the  urethra,  the  first  indication  consists 
in  locating  the  seat  of  the  stricture,  after  which  the  treatment  suited  best 
for  the  case  is  carried  into  effect.  Sometimes  supplemental  steps,  such 
as  opening  the  stomach  or  oesophagus,  are  needed  to  bring  the  stricture 
within  the  proper  reach  of  the  curative  manipulations.  Bulbous  bougies 
(Fig.  852)  are  the  common  diagnostic  agents  employed.  The  fluoroscope, 
when  used  in  connection  with  a  metallic  bougie  or  with  any  shadow-cast- 
ing substance  introduced  into  the  oesophagus,  affords  an  excellent  means 
of  locating  a  stricture  and  of  computing  its  relations  to  contiguous  bone 
structures.    The  oesophagoscope  is  useful,  but  should  be  carefully  employed. 

Dilatation  is  the  simplest  and  safest  method  of  practice  in  non-malig- 
nant stricture.  Direct  and  retrograde  dilatation  are  the  methods  employed. 
The  variously  formed  and  sized  bougies  are  utilized  for  the  purpose,  and 
the  finest  filiform  variety  may  fail  to  pass.  The  size  should  be  increased 
from  time  to  time,  and  when  directly  used,  the  instrument  should  be  intro- 
duced in  the  manner  already  described  (page  665). 


OPERATIONS  ON  THE  (ESOPHAGUS. 


673 


The  introduction  is  practiced  once  in  two  or  three  days,  according  to  the 
characteristics  of  the  constriction.  The  possibility  of  the  presence  of  aneu- 
rismal  constriction  of  the  tube  should  be  eliminated  before  an  attempt  is 
made  to  overcome  the  obstruction. 

Retrograde  Dilatation. — Retrograde  dilatation  is  directed  to  the  treat- 
ment of  stricture  of  the  lower  portion  of  the  oesophagus  by  way  of  an  open- 
ing through  the  stomach  (gastrotomy),  made  as  for  the  removal  of  foreign 


Fig.  852. — Instruments  employed   in  treatment  of  stricture  of  the  oesophagus. 
Whalebone  bougie,   bulbs  of  assorted    sizes,      h.   Sands's  cesophagotome,  bulbs  of 
assorted  sizes,     c,  d.  Bulbous  and  pointed  bougies,     e.  Bougie  with  string  attach- 
ment.   /.  String  for  friction  purposes.     Bougies  of  various  materials  and  of  assorted 
sizes  are  for  sale. 


bodies,  or  through  the  fistula  of  gastrostomy,  as  the  nature  of  the  case  shall 
determine.  And  in  neither  instance  shotild  the  opening  into  the  stomach 
be  so  small  or  so  placed  as  to  interfere  with  ready  approach  to  the  cardiac 


674  OPERATIVE   SURGERY. 

orifice.  Dilatation  may  be  produced  by  the  finger  or  by  any  of  the  stereo- 
typed urethral  or  uterine  dilators  of  suitable  size  and  shape;  also  sponge 
tents,  laminaria,  and  conical  metal-capped  bougies  with  string  attachment 
are  utilized  for  the  purpose.  Various  devices  for  the  primary  introduction 
of  a  dilating  agent  are  employed.  The  swallowing  of  a  shot  attached  to  a 
string  (Socin)  in  advance  of  opening  the  stomach,  and  the  pulling  of  the 
shotted  end  through  the  gastric  opening  to  secure  the  return  of  a  bougie  or 
friction  string  or  rubber  tube  (Ochsner)  is  an  effective  measure. 

Thus  Knott's  conical  bougies,  or  laminaria  or  rubber  tubes  of  in- 
creasing sizes,  may  each  be  drawn  upward,  dilating  the  stricture.  It  is  some- 
times difficult  to  locate  the  cardiac  aperture  after  opening  the  stomach,  be- 
cause of  the  obliteration  of  the  orifice.  The  localization  of  it  with  the  finger 
or  with  a  bougie,  as  already  described  (page  672),  may  be  practiced.  The 
introduction  of  an  endoscope  along  a  string  passed  down  from  above  (Sil- 
ver), or  of  a  tunneled  catheter,  may  suffice.  Direct  observation  through 
the  endoscope  at  the  seat  of  the  opening  may  detect  the  entrance  to 
the  stomach  from  above  of  fluid  swallowed  for  the  purpose  (Lange) 
(see  page  663).  Other  ingenious  devices  can  be  named,  but  sufficient 
is  noted  already  to  invite  the  exercise  of  discreet  and  fertile  judgment  in 
this  regard. 

Divulsion. — Divulsion  of  an  obstruction  is  not  as  safe  a  procedure  as 
dilatation.  However,  in  the  case  of  failure  of  the  latter,  divulsion  can  be 
carefully  practiced  when  necessary,  in  the  absence  of  other  means  of  treat- 
ment. Direct  and  retrograde  divulsion  are  employed.  The  former  consists 
in  the  introduction  through  the  stricture  in  prompt  succession  of  two  or 
more  oesophageal  bougies  of  graded  size,  with  sufficient  vigor  to  rupture  in 
a  minor  degree  the  contracted  tissues  of  the  obstruction.  The  latter  is  prac- 
ticed in  a  rapid  and  forcible  manner  through  an  opening  into  the  stomach 
by  the  agents  employed  in  dilatation. 

The  immediate  results  are  quite  satisfactory,  and  the  patency  of  the 
tube  may  be  maintained  thereafter  by  the  continued  introduction  of  bou- 
gies by  the  direct  method.  External  division  or  external  oesophagotomy  has 
been  considered  already  (page  668).  Strictures  of  the  cervical  portion  of  the 
oesophagus  may  be  divided  from  without.  The  stricture  is  first  located  by  a 
bougie  introduced  into  the  tube,  and  is  then  cut  down  upon  through  an  ex- 
ternal incision  as  in  oesophagotomy. 

Internal  (Esopliagotoniy  (Internal  division). — Internal  resophagotomy 
consists  in  the  division  of  the  constricting  tissue  after  the  manner  of  ure- 
thral practice,  with  enlarged  patterns  of  the  instruments  employed  in  in- 
ternal urethrotomy  (Fig.  852,  h).  An  instrument  arranged  so  as  to  be 
passed  upon  a  guide,  as  in  internal  urethrotomy,  has  been  successfully  em- 
ployed on  several  occasions  in  internal  oesophagotomy.  However,  the  con- 
tiguity of  important  anatomical  structures,  and  the  inability  to  comprehend 
the  exact  relations  of  the  stricture  to  the  outer  wall  of  the  tube,  make  the 
operation  an  exceedingly  hazardous  one.  If  it  be  attempted,  the  constric- 
tion should  be  incised  only  sufficiently  to  admit  a  bougie,  by  means  of  which 
dilatation  should  be  subsequently  practiced. 


OPERATIONS  ON  THE  CESOPHAGUS. 


6Y5 


The  Results. — In  nineteen  cases  of  internal  cesophagotomy  treated  by 
incision,  one  third  died  in  sixteen  davs  from  results  associated  with  the 


Fig.  853. — Abbe's  string  friction  method ;  string  escaping  through  a  low  cervical 
cesophagotomy  instead  of  through  the  mouth. 

operation.  Of  the  remainder,  three  are  said  to  have  recovered,  while  the 
others  survived  for  a  period  from  one  month  to  several  years.  xA.bout  one 
third  of  the  cases  required  one  or  more  repetitions  of 
the  operation. 

The  division  of  the  stricture  hy  means  of  string 
friction,  as  devised  by  x4.bbe  and  practiced  by  him- 
self and  others,  is  a  decided  advance  along  the  line 
of  safety  in  the  treatment  of  stricture  of  the  oesopha- 
gus. The  stomach  is  opened  sufficiently  to  admit  two 
fingers,  along  which  as  a  guide,  a  bougie  carrying  a 
long  silk  thread  is  passed  up  the  oesophagus  and  out 
of  the  mouth  (Fig.  853).  The  lower  end  of  the  string 
is  seized  and  the  stricture  made  tense  by  the  introduc- 
tion of  a  conical  bougie  (Fig.  85i) ;  after  which  the 
upper  end  of  the  string  is  grasped  and  carried  well 
back  into  the  pharynx,  while  the  lower  end  is  carried 
into  the  stomach;  then  the  string  is  drawn  tight 
and  moved  rapidly  upward  and  downward  several 
times  until  the  constricting  bougie  is  released.  This 
bougie  is  removed  and  the  tension  at  the  site  of  con-  4 
striction  renewed  by  the  introduction  of  a  larger  one, 
and  so  on  until  the  oesophageal  tube  is  permeable  or 
firm  resistance  is  encountered  by  the  string.  As 
soon  as  a  suitable  sized  bougie  can  be  passed  by  the 
mouth,  the  operation  is  discontinued,  the  string  is 
removed,  the  abdominal  openings  are  closed,  and 
thereafter  bougies  are  introduced  at  reo;ular  inter-  Fig.  854. — Making  tense 
vals  until  all  fear  of  closure  ceases.     It"  is  not  f re-  *^^  stricture, 

quent  that  the  conditions  require  the  oesophageal  incision,  only,  in  fact, 
when  the  manipulations  through  other  channels  are  futile,   insufficient, 


676 


OPERATIVE  SURGERY. 


Fig.  855. 

String  friction  employed 

through  mouth  only. 


or  needlessly  dangerous  to  the  patient.  The  author  suggested  not  long 
since  the  employment  of  string  friction  through  the  mouth  alone  in  the 
following  manner:  Introduce  a  long,  firm,  silken  thread  through  an  open- 
ing made  transversely  at  the  advancing  end  of  a  bougie  (Fig.  852,  e).  In- 
troduce the  bougie  through  the  mouth  into  the  grasp 
of  the  stricture  (Fig.  855),  then  seizing  the  ends  of 
the  thread  make  the  rapid  sawing  motion  while  press- 
ing downward  upon  the  bougie,  the 
thread  being  thus  made  to  move  to  and 
fro  through  the  hole  in  the  end  of  the 
bougie  as  over  a  pulley.  The  connec- 
tion to  the  advancing  end  of  the  bougie 
of  a  small  adjustable  wheel  (Fig.  856, 
a),  around  which  the  thread  will  move, 
and  the  passing  of  the  ends  of  the  string 
through  projecting  arms  provided  with 
wheels  (Fig.  856,  &),  facilitate  the  move- 
ments of  the  string.  If  a  hollow  bougie 
be  employed,  the  apparatus  can  be  sim- 
plified by  carrying  the  ends  of  the  string 
into  the  bougie  through  openings  at 
the  lower  part,  and  thence  upward  and 
out  of  the  upper  extremity  suflficiently 
far  to  permit  of  proper  handling.  In 
every  instance  the  bougie  should  be  a 
stiff  one,  and  the  end  should  not  be 
carried  far  into  the  stricture  before  the 
string  is  brought  into  play.  By  this 
method  of  employment  of  the  string 
the  time  of  use  is  much  lessened  and 
the  therapeutic  effect  greatly  increased. 
It  is  not  impossible,  therefore,  to  reduce  the  stomach  feature 
of  the  operation  if  desired  from  two  steps  to  one,  and  perhaps 
in  some  cases  to  avoid  it  altogether,  by  this  method  of  employ- 
ment at  either  aspect  of  the  obstruction,  of  string  friction. 

The  Comments. — In  the  event  of  failure  to  dilate  the  stric- 
ture by  way  of  the  mouth  the  surgeon  must  supplement  the 
effort  by  the  advantages  arising  from  the  performance  of  gas- 
trotomy  or  gastrostomy.  The  enfeebled  condition  of  many  of 
the  patients  with  oesophageal  stricture  from  lack  of  nourish- 
ment, and  the  tendency  of  obstinate  strictures  to  relax  after 
a  longer  or  shorter  quiescence  of  the  tube,  have  led  to  increased 
frequency  of  employment  of  the  latter  plan,  in  order  to  permit  of  ample  and 
immediate  nutrition  and  to  afford  the  rest  to  the  oesophagus  essential  to  stric- 
ture relaxation.  Silver  regards  those  cases  characterized  by  impassable  stric- 
ture and  pronounced  regurgitation— the  latter  indicating  decided  pouching  of 
the  oesophagus — as  suitable  for  prompt  gastrostomy.    Cancer  of  the  oesopha- 


FiG.  856. 

String  friction 

appliance. 


OPERATIONS  ON  THE  ESOPHAGUS.  67Y 

gus,  especially,  calls  for  early  relief  by  this  method.  The  opening  into  the 
stomach  should  be  made  of  sufficient  size  to  admit  one  or  two  fingers  along 
with  the  necessary  instrument  for  dilatation,  and  be  placed  well  up  on  the 
anterior  surface  to  permit  of  as  easy  access  to  the  cardiac  orifice  as  possible, 
and  also  to  limit  the  danger  of  leakage  during  the  manipulation.  The  bor- 
ders of  the  gastric  opening  can  be  drawn  apart  by  traction  loops,  to  afford 
better  observation,  or  they  may  be  drawn  by  the  loops  closely  against  the 
exploring  agent,  thus  lessening  the  danger  of  escape  of  the  contents  of  the 
stomach.  This  opening  may  be  closed  independently  of  the  abdominal  one, 
provided  dilatation  sufficient  to  allow  the  ready  passage  of  fluid  food  and  the 
employment  of  bougies  from  above  have  taken  place.  The  dilatation  should 
be  completed  at  a  single  sitting,  if  possible.  If  preliminary  gastrostomy  be 
performed,  it  is  safer,  other  things  being  equal,  that  two  sittings  be  given  to 
the  operation  than  that  it  be  completed  at  one. 

Tfie  After-treatment. — The  passage  of  the  largest  bougies  practicable  once 
a  week  or  once  a  month,  according  to  the  demands  of  the  case,  supplemented 
with  the  free  use  of  solid  food  and  the  giving  of  exacting  admonitions  re- 
garding the  need  of  surgical  surveillance  for  an  indefinite  time  to  come,  are 
essential  to  final  success. 

The  Results. — The  results  of  retrograde  dilatation  are  very  satisfactory 
indeed.  Woolsey  reports  twenty-eight  cases  "  with  no  death  due  to  the 
operation."  To  this  number  Silver  has  added  ten  with  no  change  in  the 
immediate  results  of  the  operation.  .  The  final  outcome  is  much  enhanced 
indeed  by  prompt  resort  to  opening  of  the  stomach.  A  steady  and  persistent 
loss  of  weight,  due  to  obstruction  in  swallowing,  forbids  temporizing,  and 
demands  prompt  and  radical  operative  practice. 

Tubage  with  String  Attachment. — This  plan  is  adapted  to  the  treatment 
of  malignant  strictures,  and  is  practiced  on  those  patients  in  whom  for  any 
reason  early  gastrostomy  is  not  practicable.  While  it  is  true  that  through 
the  agency  of  tubage  ample  food  may  be  taken  for  a  time,  also  the  saliva 
swallowed,  and  the  objections  to  early  operation  condoned,  still,  the  progress- 
ive nature  of  the  disease  causing  the  obstruction,  the  effect  on  the  disease  of 
pressure,  and  the  dangers  and  annoyances  of  the  introduction  and  retention 
of  the  tubes,  especially  in  the  advanced  stages,  together  with  the  opportunity 
afforded  for  procrastination  of  operative  practice  until  much  too  late  for  fit- 
ting success,  suggest  the  fact  that  tubage,  although  an  ingenious  and  some- 
times temporarily  useful  means  is,  on  the  whole,  a  measure  of  questionable 
utility.  However,  the  tube  finds  its  most  rational  use  in  cases  unsuited  for 
operation.  The  method  is  practiced  by  introducing  into  the  stricture  by 
means  of  a  whalebone  conductor  a  funnel-shaped  flexible  gum-elastic  tube 
with  a  string  attached  (Fig.  857,  h)  four  to  six  inches  in  length,  until  the 
funnel  rests  above  on  the  stricture.  The  lower  end  of  the  tube  resembles 
that  of  the  ordinary  catheter,  except  the  eye  is  made  larger  to  permit  the 
free  passage  of  fluid  food.  The  tube  can  remain  in  place  often  from  one  to 
two  months  without  causing  apparent  trouble.  The  string  escapes  through 
the  mouth  and  is  carried  over  the  ear  for  both  security  and  convenience.  It 
should  be  carefully  guarded  to  prevent  premature  withdrawal  of  the  tube 


678 


OPERATIVE  SURGERY. 


because  of  careless  traction,  and  difficult  removal  on  account  of  the  breaking 
of  the  string.  Sometimes  coughing  attends  deglutition,  and  then  the  short 
tube  should  be  replaced  by  a  long  one,  which  can  be  easily  extemporized  by 
cutting  obliquely  and  closing  the  end  of  a  suitable  piece  of  red-rubber 
a  tubing,  making  the  eye  about  an 

inch  above  the  end,  and  introduc- 
ing it  through  the  stricture  with 
a  suitable  conductor. 

The  Results. — Of  seventeen 
cases  treated  by  this  method,  nine 
died  from  the  efEects  of  the  dis- 
ease, without  obstructed  degluti- 
tion. 

(Esophagectomy. — CEsophagec- 
tomy  consists  in  excising  a  por- 
tion of  the  oesophagus  through 
an  incision  made  in  the  same 
manner  as  for  cervical  cesopha- 
gotomy  (jjage  668)  or  for  thora- 
cotomy, for  the  removal  of  a 
cancerous  growth.  In  the  for- 
mer the  upper  end  of  the  lower 
portion  of  the  tube  is  raised  for- 
ward and  united  to  the  wound, 
thereby  forming  an  opening 
through  which  food  may  be  in- 
troduced b}^  means  of  a  tube. 
The  latter  method  is  noted  under 
the  proper  heading  (page  1388 
et  seq.). 

The  Results. — Butlin  reports 
14  cases,  5  dying  of  operation, 
1  from  a  false  passage,  a  short 
time  after;  6  dead  or  alive  with 
return,  and  2  unreported.  There 
is  reason  to  believe  that  life  can  be  extended  for  a  longer  time  by  gastros- 
tomy or  by  feeding  through  a  tube  than  by  this  procedure. 

(Esopliagostoiny. — CEsophagostomy  is  employed  to  establish  a  fistulous 
opening  with  the  oesophagus,  below  the  point  of  an  incurable,  impassable 
constriction.  It  provides  for  the  introduction  of  food  into  the  stomach,  and 
serves  as  a  temporary  palliative  measure.  While  its  adoption  obviates  for  a 
time  at  least  the  performance  of  gastrostomy,  still  there  is  no  good  reason 
to  believe  that  it  can  be  regarded  in  any  instance  as  the  wiser  procedure. 

Diverticula  of  the  (Esophagus. — These  pouches  may  be  either  con- 
genital, or  arise  from  stricture,  from  external  pressure  or  from  in- 
ternal contraction.  When  occurring  in  the  neck  they  can  be  quite  readily 
removed. 


Fig.  857. — a.  Tube  conductor,  b.  Gum-elastic 
tube,  c.  Small  flexible  bougie,  d.  Bulbous 
bougie. 


OPERATIONS  ON  THE  (ESOPHAGUS. 


679 


The  Operation. — Anaesthetize  the  patient,  pass  a  curved  ])Ougic  into 
the  pouch,  noting  its  presence  by  external  pressure;  pass  another,  if  possi- 
ble, into  the  stomach,  thus  determining  the  exact  location  of  the  oesophagus 
and  the  absence  of  stricture;  make  an  incision  at  the  anterior  border  of 
the  left  sterno-mastoid  muscle  from  the  hyoid  bone  to  just  above  the 
sternum;  divide  the  omo-hyoid  and  the  superior  thyroid  vessels;  draw  out- 
ward the  carotid  sheath  and  rotate  the  larynx  outward  with  blunt  hooks, 
thus  exposing  the  pouch;  isolate  carefully  the  pouch  by  dissection,  aided 
by  movement  of  the  included  bougie;  grasp  the  pouch  with  forceps  and 
draw  it  carefullv  from  the  wound  (Fig.  858) ;  cut  away  the  diverticulum 


Fig.  858. — (Esophageal  diverticulum  dissected  out  ready  for  removal. 


from  above  downward,  closing  the  wound  witli  fine  silk  or  chromicized 
catgut  sutures;  close  the  ends  of  the  wound,  introducing  gauze  wicks 
or  gauze  packing  lightly  into  the  central  part,  and  apply  the  usual  external 
dressings. 

The  Picmarls. — Richardson,  in  one  case,  cut  away  the  pouch  (Fig.  858), 
inverted  the  mucous  memlu'ane,  united  its  borders  with  catgut  (Fig.  859) 
and  those  of  the  outer  layer  of  the  oesophagus  with  silk  siitures,  followed 
by  good  results  (Fig.  8()0).  In  another  case,  while  passing  the  finger 
through  the  opening  to  estimate  a  stricture  below,  a  longitudinal  rupture 


Fig.  859. — Diverticulum  removed  and  borders  of  mucous  membrane  united. 


Fig.  860. — Line  of  union  of  mucous  membrane  covered  by  union  of  outer  coats. 
680 


OPERA'J'IONS  ON  THE   NECK.  681 

happened  below  the  stricture.  The  border  of  tlie  opening  and  the  stricture 
were  then  divided  down  into  the  rupture.  A  portion  of  the  pouch  left 
above  was  turned  down  and  attached  to  the  incised  posterior  surface  of 
the  longitudinal  division  of  the  oesophagus,  the  gap  united  transversely, 
as  in  pyloroplasty,  and  the  original  opening  of  the  pouch  closed  in  a  verti- 
cal line. 

Girard  invaginatcd  the  jx)uch  and  closed  the  opening  externally  by 
three  la3'ers  of  sutures,  thus  avoiding  opening  into  the  oesophagus.  The 
invaginated  pouch  atrophied,  causing  no  obstruction.  The  great  danger 
of  leakage  forbids  complete  closure  at  once  of  the  wound. 

27; c  aftcr-trcatiiient  differs  in  no  essential  regard  from  that  of  oesopha- 
gotomy.     Solid  food  ought  not  to  be  taken  for  five  or  six  days. 

The  Results. — Of  22  cases  operated  on,  5  resulted  fatally  (Veiel*). 

OPERATIONS    ON    THE    NECK. 

Bronchotomy. — The  expression  bronchotomy  includes  four  distinct  opera- 
tions: lanjngotomy,  traclieotomy,  laryngo-traclieotomy,  and  thyrotomy,  the 
first  two  of  which  are  still  further  classified.  These  operations  are  compar- 
atively easy  in  the  adult,  especially  if  the  neck  be  long  and  thin,  and  the 
landmarks  well  developed.  In  the  infant  and  the  child,  and  before 
puberty — the  periods  of  life  when  they  are  most  demanded — their  per- 
formance is  difficult  and  perplexing,  owing  to  the  shortness  of  the  neck. 
obesity  of  the  patient,  the  rudimentary  condition  of  the  landmarks,  and  the 
exigencies  of  the  occasion. 

The  Anatomical  Points. — The  trachea  in  the  adult  is  about  four  inches 
and  a  half  in  length  and  three  quarters  of  an  inch  from  side  to  side.  The 
distance  between  the  sternum  and  the  cricoid  cartilage  is  about  two  and 
three  quarters  inches  in  the  adult,  and  two  and  a  quarter,  two,  and  one  and 
a  half  at  ten,  seven,  and  five  years  respectively.  The  following  illustrative 
scheme  (Treves)  shows  the  relation  between  the  respective  ages  and  sizes  of 
the  corresponding  tubes  (Fig.  861).  Deviations  from  the  normal  size  of  the 
trachea  from  congenital  and  acquired  influences  are  so  infrequent  as  not  to 
figure  significantly,  except  perhaps  in  adults,  and  then  from  pressure  effects 
already  well  understood. 

OOOOQ 

a  h 

Fig.  861. — Comparative  diameters  of  tracheotomy  tubes  based  on  age  of  patients,  a. 
.47  +  inch  (12  mm.),  twelve  to  fifteen  years,  b.  .40  —  inch  (10  mm.),  eight  to  ten 
years,  c.  .31  +  inch  (8  mm.),  four  to  eight  years,  d.  .34  —  inch  (6  mm.),  two  to  four 
years,  e.  .20  —  inch  (5  mm.),  one  and  a  half  to  two  years.  Adults,  +  to  f  inch; 
under  one  year  and  a  half,  .15  -i-  inch. 

The  thyroid  cartilage  (Fig.  862,  c),  which  is  well  marked  in  the  adult,  con- 
stituting a  prominent  point  of  reckoning,  is  scarcely  discernible  in  the  child, 

*  Annals  of  Surgery,  Jan.,  1901. 
45 


682 


OPERATIVE  SURGERY. 


and  in  the  infant  it  is  quite  impracticable  to  determine  its  location  by  physical 
examination.  The  cricoid  cartilage  (e)  is  a  far  better  guide  by  which  to  deter- 
mine the  comparative  relations  of  the  parts.  It  is  the  distinctive  cartilage  of 
the  laryngeal  group,  and,  irrespective  of  age,  it  can  be  felt  as  a  firm,  round 
ring,  much  more  prominent  than  the  cartilaginous  rings  of  the  trachea,  which 
lie  immediately  below  it.  The  crico-thyroid  space  (d),  through  which  in 
laryngotomy  the  deep  incision  is  made,  is  located  immediately  above  the 
cricoid  cartilage  (Fig.  8(32).  This  space  is  situated  at  the  bottom  of  the  first 
groovelike  depression  aboye  the  cricoid  cartilage.  The  crico-thyroid  mem- 
brane (d)  is  composed  of  yellow  elastic  tissue,  is  therefore  of  a  yellowish 
appearance,  and  is  often  dotted  by  openings  for  small  vessels.  When  incised 
it  will  retract,  owing  to  its  resilient  nature ;  hence  all  haemorrhage  should  be 

stopped  before  it  is  opened  if  the  urgency  of 
the  case  will  permit.  It  is  not  difficult  to 
locate  the  guides  in  the  dead  subject  under 
ordinary  circumstances;  but  in  the  living 
when  they  are  being  jerked  upward  and 
downward  by  the  efforts  of  impeded  respira- 
tion, it  is  a  matter  of  great  difficulty,  and 
may  be  impossible.  The  only  artery  nor- 
mally in  the  line  of  the  operation  of  laryn- 
gotomy that  need  be  respected  is  the  crico- 
thyroid (Fig.  863,  d);  it  runs  along  the 
upper  border  of  the  space,  resting  on  the 
membrane  of  the  same  name.  This  artery  is 
troublesome,  not  from  the  amount  of  blood 
it  contains,  but  from  its  relation  to  the  open- 
ing in  the  membrane  through  which  a  small 
amount  of  blood  may  pass  into  the  tube. 
The  vessels  causing  the  greatest  annoyance 
— especially  if  the  patient  be  much  cyanosed 
— are  the  small  venous  trunks  which  run 
across  the  tracheal  and  laryngeal  region, 
without  any  definitely  established  relation- 
ship, and  which  return  their  blood  chiefly 
into  the  superior  thyroid  veins  (Fig.  863). 
The  anterior  jugular  veins  will  be  trouble- 
some unless  the  median  line  be  adhered  to  closely.  It  is  unnecessary,  I  trust, 
to  allude  to  the  well-known  relation  between  the  larynx  and  the  large  vessels 
of  the  neck.  The  thymus  gland  in  the  very  young  deserves  respectful 
manipulative  consideration.  The  innominate  and  common  carotid  arteries, 
especially  in  the  right,  may  encroach  on  the  operation  in  low  tracheotomy. 

The  ancBstlietic  to  be  given  in  operations  where  the  respiratory  function 
of  the  larynx  is  involved  is  a  matter  entitled  to  careful  consideration.  For 
instance,  if  ether  be  given  to  one  who  has  no  laryngeal  irritation  or  obstruc- 
tion, the  frequent  spasm  of  those  parts  is  familiar  to  all.  If  to  this  be  added 
the  deficient  aeration  of  the  blood,  due  to  a  laryngeal  obstruction,  together 


Fig.  863.— The  topography  of  the 
larynx,  etc.  a.  Body  of  hyoid 
bone.  h.  Thyro-hyoid  membrane, 
c.  Thyroid  cartilage,  d.  Crico- 
thyroid membrane.  e.  Cricoid 
cartilage.  /.  First  tracheal  ring. 
g.  Isthmus  of  thyroid  body,  with 
tracheal  rings  below,  h.  Crico- 
thyroid muscle. 


OPERATIONS  ON  THE   NECK. 


683 


willi  the  increased  tendency  to  spasm,  dependent  on  laryngeal  disease  and  to 
fright,  then  is  the  danger  of  asphyxia  greatly  augmented.  Chloroform  may 
be  given  with  l)ut  little  danger  of  causing  spasm;  if  ether  be  administered, 
it  must  be  commenced  very  gradually,  to  avoid  as  much  as  possible  the 
occurrence  of  laryngeal  spasms.  In  many  instances  the  pressing  nature  of 
the  case  will  not  per- 
mit the  expenditure  of  -^  i  -^-^^^^x&v^^^ 
the  time  necessary  to 
produce  general  anaes- 
thesia. Local  anaes- 
thesia may  be  em- 
ployed. In  those  cases 
presenting  marked  cy- 
anosis the  sense  of 
pain  is  much  blunted 
and  the  operation 
should  he  done  with- 
out anaesthesia.  The 
instruments  suitable 
for  these  operations 
(Fig.  864)  are  quite 
numerous,  yet  the  ab- 
sence of  any  one  or 
more  of  them  is  not 
to  be  considered  a 
reason  for  non  -  per- 
formance of  bronchot- 
oni}^  when  demanded. 
When  necessary,  a 
pocketknife,  and  a 
hairpin,  a  toothpick,  or  a  catheter  (Fig.  864)  can  be  extemporized  to  advan- 
tage, thus  preventing  the  death  of  the  patient  unaided  because  a  tracheotomy 
tube  is  not  obtainable. 

Langenbeck's  hook  (Fig.  865)  is  the  best  in  use,  because  the  line  of  the 
cut  can  be  made  between  its  blades,  and  the  middle  line  of  the  trachea  is 
therefore  the  better  assured.  There  are  various  forms  of  tracheotomes, 
which  should  not,  in  our  opinion,  be  substituted  for  the  sharp-pointed 
bistoury,  because  they  are  much  less  surgical  in  their  inception  and  far 
more  dangerous  in  their  use.  Trachea  dilators,  too,  are  quite  numerous 
and  varied  in  pattern  (Fig.  864,  p,  q,  r).  The  borders  of  the  tracheal  open- 
ing can  always  be  easily  drawn  apart  by  common  tenacula  or  by  two  of  the 
ordinary  grooved  directors  with  aneurism-needle  attachments  (Fig.  864.  e). 
The  bivalve  trachea  tube  is  an  admirable  instrument,  since  it  can  be  intro- 
duced through  the  opening  in  the  trachea  much  more  readily  than  the  ordi- 
nary blunt-ended  pattern,  and  can  be  quickly  opened  afterward  by  the  intro- 
duction into  it  of  the  companion  tube  (Fig.  864,  n).  A  long  feather,  with 
the  end  of  the  brush  remaining  (Fig.  864,  ;/),  sliould  be  at  hand  to  insert 
45* 


Pig.  863. — The  surgical  anatomy  of  larynx  and  trachea,  a. 
Thyroid  cartilage,  h.  Crico-thyroid  membrane  and  ar- 
tery, erico-thyroid  muscle  at  either  side.  c.  Ci-icoid  car- 
tilage, d.  Superior  thyroid  vein.  e.  Infei'ior  thyroid 
vein.  /.  Innominate  artery,  g.  Thymus  gland,  h. 
Sterno-hyoid  muscle,  i.  Omo-hyoid  muscle.  /.  Sternal 
attachment  of  sterno- mastoid,  h.  Jugular  vein  and 
branches.  1,1,  Carotid  arteries  and  branches,  m.  Ster- 
num,    n.  Thyroid  body. 


Fig.  864.— Instruments  employed  in  operations  on  the  trachea. 

a.  Scalpels,  sharp  and  probe-pointed,  h.  Scissors,  curved  and  straight,  blunt-pointed,  c. 
Forcipressure.  d.  Mouse-tooth  forceps,  e.  Directors  with  hooked  extremities.  /. 
Blunt  hook.  g.  Strong  tenaculum,  h.  Two-tined  retractor,  i.  Small  blunt  re- 
tractor, h.  Rubber  tracheotomy  tube  with  tapes  attached.  I.  Hard-rubber  tube.  m. 
Gussenbauer's  tube.  n.  Bivalve  tube.  o.  Konig's  tube.  p.  Trousseau's  trachea 
dilator,  q.  Tiemann's  dilator,  r.  Chassaignac's  dilator,  s.  Hairpin,  pocketkmfe, 
and  female  catheter,  t.  Trachea  forceps.  «.  Feather  for  introduction  to  trachea,  v. 
Trachea  forceps,  w.  Trachea  aspirator,  x.  Ligatures,  traction  loops,  and  sutures. 
Spatula,  mouth  gag,  tongue  forceps,  wipers,  and  shield,  for  mouth  and  eyes  of  opera- 
tor in  diphtheria,  ought  to  be  at  hand.  Genzmer's  modification  of  Konig's  tube  (o) 
is  valuable. 
684 


OPERATIONS  ON  THE   NECK. 


685 


through  the  tube  into  the  trachea,  to  create  the  irritation  sometimes  neces- 
sary to  cause  the  expulsion  of  the  tracheal  mucus.  A  so-called  trachea  aspi- 
rator has  been  devised  to  remove  mucus  and  blood  from  the  trachea  (Fig. 
864,  iv).  It  is  used  as  follows:  After  the  insertion  of  the  trachea  tube, 
place  the  thumb  on  the  air-hole  of  the  barrel ;  apply  the  soft-rubber  cup  over 
the  tube,  and  withdraw  the  piston,  when  the  mucus  and  blood 
will  enter  the  barrel.  It  has  not  infrequently  happened  tliat  a 
patient  is  unable  to  expel  the  blood  and  mucus  on  account  of 
stupor  or  weakness,  and  the  lips  of  the  operator  were  used  to 
clear  the  trachea.  This  is  obviously  a  hazardous  procedure  if 
the  patient  have  syphilis  or  diphtheria.  Tlie  possession  of  the 
tracheal  aspirator  will  be  welcomed  as  preferable  under  all  cir- 
cumstances. A  serviceable  instrument  for  the  purpose  of  re- 
moving blood,  etc.,  from  the  trachea  tube,  and  even  from  the 
trachea  itself,  can  be  quickly  extemporized  by  attaching  to  the 
nozzle  of  an  ordinary  two-ounce  rubber  syringe  a  soft  piece 
of  rubber  tubing  five  or  six  inches  in  length.  The  unattached 
end  of  the  rubber  tubing  is  inserted  into  the  trachea  tube  or 
into  the  trachea  itself ;  the  piston  of  the  syringe  is  withdrawn 
somewhat  quickly,  and  the  fluid  sucked  up.  If  the  suction 
be  made  too  quickly  the  tube  will  be  collapsed  and  inopera- 
tive. Large  portions  of  membrane  have  been  drawn  by  the 
writer  from  the  bronchial  tulles  in  this  manner. 

The  After-treatment. — The  soft  jaarts  above  and  below  the 
tubes  are  closed  by  sutures  and  the  patient  is  then  placed  in  bed 
and  caused  to  breathe  air  saturated  with  warm  vapor  from 
which  all  floating  particles  of  dirt  should  be  excluded.  The 
tube  is  carefully  watched  to  prevent  it  from  becoming  closed, 
and  occasionally  removed  and  cleansed  to  prevent  wound  and 
pulmonary  infection.  Too  great  emphasis  can  not  be  laid  upon 
the  necessity  of  instantly  relieving  the  sudden  occlusion  of  the 
tube  due  to  false  membrane.  For  this  reason  a  momentary  inattention,  as 
leaving  the  room,  etc.,  may  prove  fatal  to  the  patient,  i^fter  three  or  four 
days  the  tube  may  be  removed  and  the  patient  allowed  to  breathe  through 
the  opening  for  a  few  hours,  after  which  the  tul)e  should  be  again  inserted ; 
later  in  the  case  it  may  be  inserted  only  during  the  night.  As  soon  as  the 
patient  can  breathe  well,  the  tube  should  be  removed  entirely,  the  opening 
cleansed,  and  the  borders  closed,  joined  by  sutures.  If  antiseptic  gauze 
(not  bichloride)  be  placed  between  the  surface  of  the  neck  (Fig.  869)  and 
the  flanges  of  the  tube,  the  danger  of  irritation  of  the  soft  parts  at  that  situ- 
ation by  the  discharges  will  be  obviated. 

Laryngotomy. — Although  all  operations  in  which  the  larynx  is  opened 
are  included  under  the  name  laryngotomy,  for  convenience  of  expression 
limited  divisions  of  the  organ  are  named  for  the  part  divided — i.  e.,  thyrot- 
omy,  cricotomy  (Figs.  866,  867),  etc. 

The  Operation. — Place  tlie  patient  on  the  table  with  the  shoulders  ele- 
vated, head  thrown  back,  and  neck  exposed  to  a  strong  light.     If  hurried,  a 


Fig.  865. 
Langenbeck's 
double  hook. 


686 


OPERATIVE  SURGERY. 


round  bottle  or  loaf  of  bread  or  block  of  wood  may  be  placed  under  the  neck, 
or  if  the  head  hang  supported  over  the  edge  of  the  bed  or  table,  the  object 

will  be  gained.  At  least 
three  assistants  are  re- 
quired, especially  if  an 
angesthetic  be  given.  Lo- 
cate the  cricoid  cartilage ; 
stipport  the  larynx  firmly 
between  the  thumb  and 
finger  of  the  left  hand; 


make  an  incision  through 


Fig.  866. — a.  Incision  in  laryngotomy.  h.  Incision  in 
tracheotomy  above  the  isthmus  of  the  thyroid  body, 
c.  Incision  in  tracheotomy  below  the  isthmus  of  thy- 
roid body,  d,  d.  Sterno-cleido-mastoid  muscles,  e. 
Incision  in  subhyoid  pharyngotomy. 


the  integument  one  inch 
and  a  half  in  length  in 
the  adult,  terminating  at 
the  lower  border  of  the 
cricoid  cartilage ;  divide 
the  fascia  on  a  director ; 
*^  divide  the  connections 
between,  and  separate  the 
borders  of  the  sterno-hyoid 
(Fig.  863)  muscles  with 
retractors;  push  aside  the 
veins  and  connective  tis- 
sue and  the  crico-thyroid 
membrane  will  be  seen  (6). 
If  the  case  be  not  urgent,  check  all  haemorrhage  before  opening  the  larynx. 
If  otherwise,  open  it  at  once,  when  the  entrance  of  air  and  the  resump- 
tion of  the  respiratory  functions  will  dispel  the  cyanosis  and  check  the 
bleeding.  The  larynx  is  seized  and  held  firmly  upward  and  forward  by  the 
tenaculum,  while  the  opening  is  made  through  the  crico-thyroid  memlDrane, 
transversely  near  the  upper  border  of  the  cricoid  cartilage,  both  to  avoid  the 
crico-thyroid  artery,  which  runs  along  the  upper  border  of  the  membrane 
near  the  thyroid  cartilage,  and  also  to  remove  the  tube  as  far  as  possible 
from  the  vocal  cords.  The  whistling  of  the  ingoing  air,  succeeded  by  an 
expulsive  cough — which  ejects  the  mucus,  blood,  and  other  matters — follow 
quickly  after  the  incision.  If  the  operation  be  performed  for  the  removal 
of  a  foreign  body  it  may  at  this  time  be  expelled,  or  become  lodged  near  the 
opening,  when  it  can  be  removed  by  forceps.  If  the  operation  be  performed 
for  laryngeal  diphtheria,  the  tube  should  not  be  inserted  until  all  loose 
membrane  has  been  expelled,  and  such  as  may  be  within  reach  of  the  for- 
ceps has  been  pulled  away.  If  blood  escape  into  the  opening  from  the 
oozing  vessels,  the  pressure  of  the  tube  upon  the  lips  of  the  woimds  will 
serve  to  check  it,  and  for  this  reason  it  may  be  introduced  promptly.  The 
tube  is  carried  carefully  in  while  the  borders  of  the  opening  are  held 
apart  with  the  orthodox  retractors,  or  by  means  of  two  blunt  artery  needles 
or  tenacula,  after  which  it  is  fastened  in  position  by  means  of  tapes  car- 
ried around  the  neck  and  tied  behind  (Fig.  869).     If  the  opening  be  too 


OPERATIONS  ON  THE  NECK. 


687 


small,  it  may  be  increased  l)y  division  of  the  cricoid  cartilage  (crico-laryn- 
goluiiiy). 

Tracheotomy. — The  operation  of  tracheotomy  consists  in  opening  the 
trachea,  and  is  usually  performed  upon  children,  owing  to  the  small  size  of 
their  crico-thyroid  spaces.  It  is  the  preferal)le  operation  in  all  instances 
when  the  incision  is  to  be  made  as  far  as  possi])le  from  a  contagious  local 
disease.  Tracheotomy  may  he  done  at  three  situations :  below  (Fig.  866,  c), 
above  (b),  and  behind  the  isthmus  of  the  thyroid  gland ;  the  operation  below 
the  isthmus  is  to  be  preferred. 

TJie  Anatomical  Points. — The  upper  portion  of  the  trachea  is  quite  super- 
ficial, while  the  lower  is  from  half  an  inch  to  one  inch  below  the  surface, 
depending  upon  the  shortness  of  the  neck  and  the  obesity  of  the  patient. 
The  lower  portion  recedes,  following  the  curve  of  the  spinal  column.  The 
vascular  structures  associated  with  this  portion  are  far  more  important  and 
numerous  than  in  other  parts  of  its  course;  the  inferior  thyroid  veins  (Fig. 
863),  and  their  communications,  pass  in  the 
course  of  the  incision;  the  arteria  thyroidea 
ima  when  present  runs  along  the  center  of  the 
trachea;  the  arteria  innominata,  especially  in 
the  child,  runs  obliquely  across  it,  at  the  root  of 
the  neck  from  left  to  right.  The  isthmus  of 
the  thyroid  covers  the  second,  third,  and  often 
the  fourth  rirgs  of  the  trachea;  above  it  is  seen 
the  communicating  branch  between  the  superior 
thyroid  veins  (Fig.  863) ;  the  thymus  gland, 
which  attains  its  full  size  at  two  years,  en- 
croaches upon  the  space  from  below  upward 
with  each  labored  respiratory  act,  and  may  be 
incised.  It  is  sometimes  difficult  for  the  begin- 
ner, when  surrounded  by  the  turmoil  incident 
to  the  operation,  to  be  certain  of  the  location  of 
the  trachea.  If  the  index  finger  be  inserted  into 
the  wound  the  trachea  will  roll  under  it,  and 
be  felt  ascending  and  descending  beneath  its 
extremity,  and,  when  sufficiently  isolated,  the 
rings  can  be  seen  and  felt.  Also,  the  inexpe- 
rienced operator  is  likely  to  open  the  trachea  at 
one  side  of  the  median  cut,  making  it  difficult 
to  introduce  the  tube,  causing  it  to  bind  after 
introduction,  and  not  infrequently,  if  the  tis- 
sues overlap  the  cut  before  its  introduction, 
causing  air  to  be  forced  between  their  planes,  creating  local  emphysema.  If 
the  knife  be  inserted  too  far,  the  posterior  wall  of  the  trachea  will  be  divided. 

The  Operation  below  the  Isthmus  (Low  Tracheotomy,  Figs.  866  and 
867). — Place  the  patient  as  for  laryngotomy,  and,  if  practicable,  employ  an 
anaesthetic.  Support  the  trachea  in  the  median  line,  and  make  an  incision 
extending  from  the  cricoid  cartilage  to  within  half  an  inch  of  the  top  of  the 


Fig,  867. — Operations  on  the 
larynx.  Z.  Hyoid  bone.  Sch. 
Thyroid  cartilage.  R.  Cricoid 
cartilage.  Th.  Outline  of  the 
thyroid  gland.  J.  Subhyoid 
pharyngotomy.  //.  I'hy- 
rotomy.  ///.  Infrathyroid 
laryngotomy.  IV.  Cricot- 
omy.  V.  High  tracheotomy. 
VI.  Low  tracheotomv. 


688 


OPERATIVE  SURGERY. 


Fig.  868. — Opening  the  trachea. 


sternum;  divide  the  fascia  on  a  director;  cautiously  separate  and  pull  aside 
the  sterno-thyroid  and  sterno-hyoid  muscles,  thus  exposing  the  deeper  cervi- 
cal fascia,  beneath  which  are  located  the  inferior  thyroid  veins  (Fig.  863), 
supported  Hy  connective  tissue.     This  fascia  should  be  torn  asunder  by  a 

blunt  instrument,  and  pushed  aside 
along  with  the  veins  and  connective 
tissue  beneath,  which  will  expose  the 
trachea.  The  blunt 
ends  of  two  ordinary 
directors  can  be  util- 
ized for  separating 
the  fascia,  or  instru- 
ments especially  de- 
vised for  dry  dissec- 
tions can  be  employed  (Fig.  49). 
Throughout  the  entire  operation  the 
tissues  must  be  draw  asunder  as  fast 
as  separated,  by  means  of  blunt  hooks 
or  other  forms  of  retractors,  to  afford 
ample  exposure  of  each  succeeding 
part.  As  soon  as  the  trachea  is  reached, 
and  all  hsemorrhage  checked,  it  is 
seized  by  one  or  two  hooks — the  double 
hook  of  Langenbeck  (Fig.  865)  being  the  best — drawn  forward  to  near  the  sur- 
face of  the  wound,  firmly  held,  and  three  or  four  rings  of  the  trachea  divided 
exactly  in  the  median  line  from  above  downward,  or  better  from  below  up- 
ward, by  a  sharp-pointed  knife  (Fig.  868).  Then  the  dilator  (Fig.  864)  is 
introduced,  and  the  tube  inserted  and 
confined  in  position  after  the  tracheal 
mucus  and  blood  have  been  expelled 
(Fig.  869).  All  incisions,  except  the 
primary  one,  should  be  directed  upward 
to  avoid  the  great  vessels  at  the  root  of 
the  neck.  The  opening  in  the  trachea 
should  be  long  enough  to  admit  the  easy 
expulsion  of  all  false  membranes  and 
foreign  bodies  (an  inch  in  length  is  not 
too  much  for  this  purpose),  and  must 
likewise  readily  admit  the  trachea  tube. 
The  Operation  above  the  Isthmus 
(High  Tracheotomy,  Figs.  866  and 
867). — Make  an  incision  of  the  usual 
length,  its  center  corresponding  to  the 
lower  border  of  the  cricoid  cartilage 
(Fig.  866,  &);  divide  and  carefully  separate  the  tissues  as  before;  the  loop 
of  communication  between  the  superior  thyroid  veins  (Fig.  863)  must  be 
carefully  drawn  upward,  the  fascial  attachment  between  the  isthmus  and 


Fig.  869. — Tube  in  position. 


OPERATIONS  ON  THE  NECK.  689 

the  cricoid  cartilage  divided,  the  isthmus  pulled  downward  and  drawn  for- 
ward by  a  blunt  hook,  when  the  trachea  can  be  opened  beneath  it  from 
below  upward,  and  the  tube  inserted  with  the  same  precautions  as  before. 

Tlie  Operation  through  the  Isthmus. — Tliis  method  is  hardly  of  enough 
practical  importance  to  be  entitled  to  a  detailed  consideration,  since  the 
opportunities  afforded  above  and  below  it  will  be  sufficient.  If,  however, 
this  position  be  selected  for  operation,  the  isthmus  should  be  divided  between 
two  ligatures  to  avoid  the  probability  of  troublesome  haemorrhage.  It  some- 
times happens  that  the  isthmus  is  small  or  too  illy  developed  to  be  trouble- 
some after  its  division  without  ligature. 

Laryngo-tracheotoiny. — In  laryngo-tracheotomy  the  larynx  and  trachea 
are  both  opened  by  a  continuous  incision,  which  is  usually  made  to  increase 
the  space,  that  foreign  bodies  and  false  membrane  may  be  removed.  The 
incision  through  the  cricoid  cartilage  and  upper  rings  of  the  trachea  is  then 
secondary  to  the  opening  of  the  larynx.  Before  the  primary  incision  is 
extended,  the  communicating  branches  of  the  superior  thyroid  veins  should 
be  pulled  downward,  the  lower  border  of  the  cricoid  exposed,  the  fascial  con- 
nections of  the  isthmus  to  it  severed,  and  the  isthmus  drawn  downward  and 
forward  as  before,  to  prevent  it  from  being  injured. 

Rapid  Laryngo-tracheotomy  {Saint- Gennain). — It  is  sometimes  neces- 
sary to  open  the  larynx  very  quickly ;  therefore,  it  is  quite  proper  to  mention 
some  of  the  points  connected  with  this  operation  that  the  surgeon  may  be 
prepared  to  act  with  dispatch  combined  with  caution. 

The  Operation. — With  the  patient  placed  in  the  usual  position  for  tracheal 
operations,  the  surgeon  locates  the  thyroid  and  cricoid  cartilages  and  the 
space  between  them.  Then,  standing  on  the  right  side  of  the  patient,  he 
seizes  and  pushes  forward  the  larynx  by  pressing  the  thumb  on  one  side  and 
index  finger  on  the  other,  between  it  and  the  vertebral  column,  thereby 
making  the  integument  tense.  At  the  same  time  the  index  finger  locates 
the  lower  border  of  the  thyroid  cartilage.  A  straight,  sharp-pointed  bistoury 
is  then  seized  between  the  thumb  and  index  and  middle  fingers,  its  back 
upward,  with  the  middle  finger  so  placed  on  the  blade  that  the  knife  can 
not  penetrate  to  exceed  half  an  inch  in  depth.  While  thus  held,  its  point 
is  quickly  thrust  into  the  larynx  in  the  median  line  at  the  lower  border  of 
the  thyroid  cartilage  and  the  blade  is  carried  downward  with  a  sawing 
motion,  dividing  the  crico-thyroid  membrane,  cricoid  cartilage,  and  one  or 
two  rings  of  the  trachea.  The  opening  through  the  integument  should 
equal  in  length  the  one  made  in  the  larynx  and  trachea.  The  dilator  is 
introduced,  all  bleeding  checked,  and  the  tracheal  tube  placed  in  position. 
Saint-Germain  up  to  1877  had  operated  by  this  method  97  times,  with  but 
three  instances  of  important  hsemorrhage,  in  one  of  which  the  posterior  wall 
of  the  trachea  was  cut. 

Thyrotomy. — Thyrotomy  consists  in  dividing  the  thyroid  cartilage  par- 
tially or  completely  in  the  median  line  (Fig.  867,  //),  together  with  division 
of  the  thyro-hyoid  and  crico-thyroid  membranes  when  additional  room  is  de- 
sired. Thyrotomy  is  performed  for  the  relief  of  laryngeal  obstruction  depen- 
dent upon  various  causes,  when  not  amenable  to  proper  aid  by  simpler  means. 


690  OPERATIVE   SURGERY. 

The  Operation. — Place  the  patient  as  for  laryngotomy,  and  after  proper 
anaesthesia  make  in  complete  thyrotomy  an  incision  through  the  skin  exactly 
in  the  median  line  from  the  lower  border  of  the  hyoid  bone  to  the  upper 
border  of  the  cricoid  cartilage,  extending  it  later  as  circumstances  require  ; 
divide  in  the  median  line  the  fascia  and  contiguous  soft  tissues  down  to  the 
cartilage,  carefully  avoiding  the  crico-thyroid  vessels ;  draw  to  either  side  the 
borders  of  the  divided  soft  parts,  exposing  the  thyroid  cartilage  and  the  upper 
portion  of  the  crico-thyroid  membrane ;  incise  the  crico-thyroid  membrane 
transversely  at  the  lower  border  of  the  thyroid  cartilage  for  a  short  distance, 
avoiding  the  crico-thyroid  artery  below  and  the  cricoid  muscles  at  either 
side ;  insert  the  point  of  a  sharp  knife  beneath  the  lower  border  of  the  thyroid 
cartilage  exactly  in  the  median  line  and  cut  upward  sufficiently  for  the  pur- 
pose of  the  operation,  leaving,  if  possible,  the  upper  border  of  the  cartilage 
unsevered  ;  divide  the  upper  border,  if  need  be,  from  within  outward  on  a 
director  with  a  blunt-pointed  knife;  draw  apart  the  respective  borders  of  the 
cartilage,  detaching  sufficiently  the  crico-thyroid  and  thyro-hyoid  membranes 
from  the  cartilage  on  either  side  of  the  larynx  to  permit  of  a  full  view  of  the 
laryngeal  cavity,  after  which  the  special  features  of  the  operation  are  carried 
into  effect. 

TJie  Precautions. — Divide  to  no  greater  extent  than  necessary  the  car- 
tilage, for,  if  complete  division  be  practiced,  it  is  difficult  to  so  adjust  the  parts 
as  to  prevent  thereafter  functional  disturbances  of  the  voice.  It  is  advised 
that  the  cartilages  be  notched  in  front,  also  that  the  sutures  be  passed 
through  the  borders  of  the  cartilages  before  complete  division  so  that  a 
more  accurate  union  of  them  may  be  afterward  secured.  Since  closure  of 
the  rima  glottidis  may  result  from  the  swelling  following  thyrotomy  and 
other  operative  manipulations,  a  tracheotomy  tube  should  be  passed  into  the 
trachea  through  the  lower  limit  of  the  wound  and  retained  as  long  as 
required,  unless  a  tube  is  already  present  below. 

The  Remarhs. — A  low  tracheotomy  should  be  performed  before  the  larynx 
is  opened,  when  the  nature  of  the  trouble  bespeaks  free  haemorrhage,  in 
which  case  tamponing  may  be  practiced.  Some  operators  place  the  patient 
in  Trendelenburg's  position,  thus  obviating  the  need  of  the  tampon.  If  the 
cartilage  is  calcified,  bone-cutting  forceps  or  strong  scissors  may  be  required 
to  make  the  separation. 

The  General  Comments. — If  the  tube  be  too  large,  too  loose,  or  too  angu- 
lar, it  is  liable  to  cause  erosions  and  ulcerations  of  the  trachea,  which  may 
extend  through  it  and  implicate  the  vessels  at  the  root  of  the  neck,  causing 
fatal  hgemorrhage.  The  method  of  opening  into  the  trachea  by  a  single 
incision  is  fraught  with  danger,  and  should  not  be  attempted  except  the  neck 
of  the  patient  be  long  and  thin,  and  not  even  then  unless  the  exigencies  of 
the  case  call  for  it.  The  division  of  the  tissues  down  to  the  trachea  by  means 
of  thermo-cautery  or  galvano-cautery  has  many  advocates ;  it  is  not,  how- 
ever, a  commendable  practice,  except,  perhaps,  in  local  infections.  The 
searing  of  the  tissues  may  prevent  or  lessen  haemorrhage,  and  likewise 
obviate  the  occurrence  of  infection.  This  is  not  altogether  true,  since  the 
large  veins  which  might  be  otherwise  avoided  are  burned  asunder  and  too 


OPERATIONS  ON  THE  NECK.  691 

often  cause  severe  h^morrluige,  which  is  uot  easily  controlled  because  of 
the  ditlloulty  of  properly  securing  the  charred  extremities  of  the  vessels. 
The  resulting  cicatrix  is  more  disfiguring  than  that  following  other  methods. 
It  is  advised  in  bronchotomy  for  diphtheria  and  acute  affections  of  the  air 
passages  that  the  tube  be  dispensed  with,  since  it  can  only  prove  a  source  of 
local  irritation,  and  obstructs  the  exit  of  false  membranes  and  the  secretions. 
As  a  substitute,  the  borders  of  the  tracheal  opening  can  be  kept,  drawn 
asunder  by  passing  looped  ligatures  through  them  (Martin),  which  are 
united  to  each  other  behind  the  neck  with  this  appliance.  The  patient 
must  be  carefully  watched,  since  if  the  head  be  turned  the  opening  may 
become  closed.  If  this  arrangement  prove  troublesome,  an  elliptical  piece 
can  be  removed  from  the  anterior  surface  of  the  trachea.  If  the  piece  to 
be  removed  exceed  a  third  of  the  diameter  of  the  tube,  the  high  operation, 
above  the  isthmus,  would  be  the  one  more  easily  and  quickly  performed, 
and  would  as  well  be  less  dangerous,  as  the  vessels  in  that  situation  are  more 
superficial,  smaller,  and  of  less  significance.  Cutaneous  emphysema,  broncho- 
pneumonia, and  pus  infiltration  of  the  thorax  are  more  liable  to  happen  in 
the  low  than  in  the  high  operation.  It  is  wise  to  confine  the  hands  and 
arms  of  the  patient  with  a  body  bandage  before  operation.  The  median  line 
of  the  neck  should  always  point  toward  the  center  of  the  episternal  notch 
during  operation.  The  trachea  should  be  seized  with  a  hook  and  held  as 
steady  as  possible  during  its  incision  and  the  introduction  of  the  tube.  The 
hissing  entrance  of  air,  coughing,  etc.,  indicate  that  the  lumen  of  the  trachea 
is  entered.  The  use  of  a  probe-pointed  bistoury  in  the  enlargement  of  the 
tracheal  wound  affords  better  protection  than  the  sharp-pointed  to  the  pos- 
terior wall  of  the  trachea.  Low  tracheotomy  is  indicated  when  it  is  desirable 
to  remove  the  opening  as  far  as  possible  from  the  seat  of  local  infection 
above,  also  from  the  seat  of  haemorrhage  in  order  that  the  entrance  to  the 
trachea  of  blood  may  be  more  surely  prevented.  Large  growths  above  call 
for  low  tracheotomy.  In  fact,  the  site  of  the  opening  is  controlled  by  the 
demands  of  the  case.  Careful  scrutiny  during  the  operation  of  low  tracheot- 
omy should  be  exercised  to  observe  and  avoid  the  innominate,  carotid,  and 
median  arteries,  also  the  active  thymus  gland  in  children.  As  silver  tubes 
sometimes  cause  the  characteristic  poisoning  of  that  metal,  it  is  better  to  use 
those  made  of  other  substances.  The  introduction  of  tubes  wrapped  in 
tightly  fitting  iodoform  gauze,  and  their  retention  for  two  days,  is  sometimes 
practiced  for  antiseptic  purposes.  If  the  tube  fits  too  tightly  erosion  of  the 
cartilage  follows.  This  sequel  is  oftener  seen  in  children  because  of  the  too 
limited  space,  in  laryngotomy  without  division  of  the  cricoid  cartilage.  A 
tube  can  be  introduced  more  Readily  and  safely  if  the  head  be  raised  up 
during  the  act.  The  employment  of  traction  loops  carried  behind  the  neck 
and  tied  together,  or  connected  with  a  small  rubber  baud  for  securer  action, 
should  be  discreetly  practiced  to  avoid  the  constriction  incident  to  swollen 
tissues  and  the  tension  arising  from  injudicious  tying  and  persistent  rubber 
traction.  Severe  and  fatal  lu\?morrhage  is  sometimes  a  part  of  the  history  of 
tlie  long-continued  use  of  a  badly  fitting  tube,  especially  in  cases  of  low 
tracheotomy.     The  presence  of  granulations  at  the  anterior  and  posterior 


692  OPERATIVE  SURGERY. 

parts  of  the  tracheal  wound  often  render  the  incautious  removal  of  the 
instrument  painful  and  dangerous  because  of  their  obstruction  to  the 
entrance  of  air. 

The  After-treatment. — The  tube  should  be  kept  in  place  until  the  cause 
for  the  operation  is  removed,  after  which  the  sooner  it  is  dispensed  with  the 
better.  However,  the  final  removal  should  be  approached  in  easy  stages  so 
regulated  as  not  to  expose  the  patient  to  the  dangers  and  discomforts  of 
obstructive  symptoms  that  are  so  often  a  part  of  the  history  of  a  case,  espe- 
cially one  of  a  prolonged  or  paralytic  nature,  in  withdrawal  of  the  tube. 
Cleanliness  of  the  wound,  absence  of  dust,  and  the  utilization  of  moistened 
and  medicated  air,  etc.,  are  the  essential  features  of  treatment.  The  assur- 
ance that  the  tube  is  open  and  securely  fixed  in  the  trachea  during  the 
danger  period  requires  constant  attention,  especially  in  children,  who  by  rest- 
lessness or  non-restraint  may  displace  or  remove  it. 

The  Results. — But  few  perish  from  the  direct  results  of  the  preceding 
operations.  Bronchitis,  infection  pneumonia,  haemorrhage  from  ulceration 
through  the  trachea  caused  by  the  tube,  and  primary  hsemorrhage  from 
wounds  of  the  vessels  at  the  root  of  the  neck,  or  from  an  abnormally  large 
crico-thyroid  artery,  constitute  the  leading  causes  of  death  directly  due  to 
the  operation.  A  deeply  cyanosed  patient,  in  the  tonic  stage  of  anaesthesia, 
may  die,  especially  if  blood  be  allowed  to  enter  the  tracheal  opening.  In 
this  contingency  the  blood  must  be  removed  at  once,  and  artificial  respira- 
tion be  resorted  to.  Tracheotomy  in  diphtheria  is  undoubtedly  a  most 
feasible  operation,  and  should  be  performed  early,  before  cyanosis  is  well 
established.  Monti,  of  Vienna,  in  his  recent  work  on  Croup  and  Diphthe- 
ria, records  12,736  tracheotomies  for  diphtheria  alone,  with  3,409  recoveries, 
or  nearly  28  per  cent.  It  is  estimated  that  25  per  cent  of  these  cases  have 
been  saved  which  otherwise  would  have  died.  About  27.5  per  cent  perish 
from  bronchotomy  for  the  removal  of  foreign  bodies.  The  use  of  antitoxine 
and  the  employment  of  intubation  have  rendered  in  this  country  the  opera- 
tion of  tracheotomy  comparatively  infrequent.  The  beneficence  of  this 
change  in  both  sentimental  and  medical  aspects  is  of  pronounced  importance. 
The  employment  of  antitoxine  at  the  proper  period,  while  not  always  pre- 
venting the  need  of  tracheotomy,  lessens  the  fatality  when  required. 

Subhyoid  Pharyngotomy. — This  operation  is  practiced  for  the  removal 
of  foreign  bodies  and  morbid  growths  situated  high  up  in  the  air  passage, 
and  for  the  relief  of  abscesses  at  the  base  of  the  epiglottis. 

The  Operation. — Place  the  patient  as  for  laryngotomy ;  administer  an 
anaesthetic,  and  make  an  incision  an  inch  and  a  half  or  two  inches  in  length 
transversely  along  the  lower  border  of  the  hyoid  bone,  with  its  center  in  the 
median  line  (Fig.  866,  e).  The  integument,  fascia,  platysma,  and  the  inner 
portions  of  the  sterno-hyoid  muscles,  and  finally  of  the  thyro-hyoid  muscles, 
are  divided  on  a  director.  The  only  vessel  contiguous  to  the  incision  is  the 
superior  thyroid  artery,  which  runs  along  the  upper  border  of  the  thyroid 
cartilage  parallel  with  the  incision.  The  thyro-hyoid  membrane  is  now 
exposed  and  opened  by  a  sharp-pointed  knife  carried  obliquely  upward. 
The  mucous  membrane  is  divided  through  the  glosso-epiglottic  fossa  aided 


OPERATIONS  ON   THE   NECK. 


693 


by  the  fingers  introduced  into  the  mouth.  If  the  greater  cornua  of  the 
hyoid  bone  be  severed  about  three  fourths  of  an  inch  from  the  extremities, 
access  to  the  pharynx  will  be  facilitated.  Divided  vessels  should  be  promptly 
tied  to  prevent  entrance 
of  blood  to  the  trachea. 
As  soon  as  the  thyro- 
hyoid membrane  is  cut, 
the  epiglottis  will  pro- 
ject through  the  open- 
ing, and  must  l)e  drawn 
aside,  when  the  tumor 
will  be  exposed  to  view 
(Fig.  870).  After  the 
removal  of  the  growth, 
the  wound  is  closed  and 
dressed  antiseptically. 
The  majority  of  the  con- 
ditions calling  for  this 
operation  can  be  satis- 
factorily treated  through 
the  mouth. 

The  Prognosis. — The 
operation   itself   implies 
no  unusual  danger  to 
the  patient. 

A  preliminary  tra- 
cheotomy   should   be 
performed   if  undue 
heemorrhage    is    an- 
ticipated, as  in  the  ex- 
tirpation  of   a   vascular 
growth,      supplemented, 
perhaps,  by  plugging  the 
trachea    in    urgent    in- 
stances.   The  Trendelen- 
burg posture  will  afford 
great  advantage. 

Intubation  of  the  Larynx.— 5o?/c/iw^,  of  Paris,  conceived  the  idea,  and 
O'Dwyer,  of  Xew  York,  by  indefatigable  and  patient  labor  achieved  the 
imperishable  distinction  of  establisliing  its  utility  upon  an  enduring  basis. 
Foreign  bodies  in  the  larynx  and  diseased  processes  contiguous  to  it,  causing 
obstructive  dyspnoea,  are,  as  a  rule,  better  treated  by  tracheotomy  than  by 
intubation.  Chronic  stenosis  of  the  larynx  from  tubercle,  syphilis,  and  other 
chronic  states  of  an  inflammatory  nature  can  be  promptly  and  often  effec- 
tually treated  by  intubation.  However,  the  chief  importance  of  the  measure 
rests  in  affording  prompt  relief  in  impending  suffocation  from  membranous 
obstruction  (Fig.  871).    The  following  is  a  description  of  the  apparatus: 


Fig.  870. — The  operation  of  subhyoid  pharvngotomy.  a. 
Hyoid  bone  with  thyro-hyoid  "membrane  attached,  h. 
Sterno-hyoid  and  omo-hyoid  muscles,  c.  Extremity 
of  greater  cornu.  d.  Entrance  to  Larynx,  e.  Superior 
laryngeal  nerve.  /.  Epiglottis,  g.  Platysma.  h.  Thy- 
roid notch. 


694 


OPERATIVE  SURGERY. 


"  The  numbers  on  the  scale  (Fig.  871,  e)  indicate  the  years  for  which  the 
corresponding  tubes  are  suitable.  For  instance,  the  smallest  tube  when 
applied  to  the  scale  will  reach  to  the  first  line,  marked  1,  and  is  intended  to 


Fig.  871. — The  O'Dwyer  apparatus  for  intubation. 

a.  Extractor,  b.  Introductor  with  obturator  attached,  c.  Obturator  detached,  d.  Tubes, 
assorted  sizes,  one  with  obturator  in  place,  e.  Scale  indicating  size  of  tube  mouth 
gag  (Pigs.  4  and  872),  also  the  O'Dwyer  gag.     Tongue  depressor  may  be  required. 

be  used  up  to  the  age  of  twelve  or  fifteen  months;  the  size  marked  2  is 
suitable  for  the  next  year,  3  and  4  for  these  years,  and  so  on.  When  the 
proper  tube  is  selected  for  the  case  to  be  operated  on,  a  loop  of  fine  thread 
about  fourteen  inches  in  length  is  fixed  through  the  small  hole  near  its 
anterior  angle,  and  left  long  enough  to  hang  out  of  the  mouth  after  the 
introduction  of  the  tube,  its  object  being  to  withdraw  the  tube  should  it 
be  found  to  have  passed  into  the  oesophagus  instead  of  the  larynx. 

"  The  obturator  (Fig.  871,  c)  is  then  fastened  tightly  to  the  introductor 
(Fig.  871,  h),  to  prevent  the  possibility  of  its  rotating  while  being  inserted, 
and  passed  into  the  tube. 

"  The  following  is  the  method  of  introducing  the  tiibe,  which  is  done 
without  the  use  of  an  anesthetic :  The  child,  with  the  arms  confined,  is  held 
upright  in  the  arms  of  a  nurse,  and  the  gag  is  (Fig.  872)  inserted  in  the 
left  angle  of  the  mouth,  well  back  between  the  teeth,  and  widely  opened; 
an  assistant  holds  the  head,  thrown  somewhat  backward.  Mobile  the  operator, 
standing  in  front,  inserts  the  index  finger  of  the  left  hand  backward  and 
downward  into  the  throat,  elevates  the  epiglottis,  draws  the  base  of  the 
tongue  forward,  and  at  the  same  time  directs  the  tube  into  the  larynx 
(Fig.  873). 

"  The  handle  of  the  introductor  (Fig.  871,  h)  is  held  close  to  the  patient's 
chest  in  the  beginning  of  the  operation,  and  rapidly  elevated  so  that  the  tube 
approaches  the  glottis  at  an  acute  angle,  and  passing  under  the  end  of  the 


OPERATIONS  ON   THE   NECK. 


695 


finger  (Fig.  874)  is  tlien  piislied  downward  in  the  median  line,  without 
using  force,  and  pressed  into  place  by  the  finger  and  the  tube  detached  (Fig. 
875).  The  joint  in  the  shank  of  the  obturator  is  for  the  purpose  of  facili- 
tating this  part  of  the  operation.  As  soon  as  the  obturator  is  removed,  and 
it  is  ascertained  that  the  tube  is  in  the  larynx,  the  thread  is  withdrawn,  l)ut 
at  the  same  time  the  finger  is  kept  in  contact  with  tlie  tul)e  to  prevent  its 
being  also  withdrawn  (Fig.  876). 

"It  is  important  that  the  attempt  at  introduction  l)c  made  f(uickly,  as 
respiration  is  practically  suspended  from  the  time  that  the  finger  enters  the 
larynx  until  the  obturator  is  removed.  It  is 
therefore,  under  tlie  circumstances,  much 
safer  to  make  several  abortive  attempts  than 
one  prolonged  effort,  even  if  successful. 

"  For  the  purpose  of  removal,  the  patient 
is  held  in  a  similar  position,  except  that  the 
head  is  not  inclined  backward,  or  very  i-iiizlil- 


B^iG.  872.— The  operation  of  intubation.    Method  of  introducing  tlie  tube.     The  respiratory 
tract  of  operator  protected  from  infection  by  mouth  shield^  and  clothing  by  a  gown. 

ly  SO,  and  the  extractor  (Fig.  871,  a)  is  passed  cautiously  and  lightly  into 
the  tube  guided  by  the  index  finger  of  the  left  hand,  which  also  fixes  the 
epiglottis,  and  is  brought  in  contact  with  the  head  of  the  tnl^e.  Firm 
pressure  with  the  thumb  is  then  made  on  the  lever,  above  the  handle,  while 
the  tube  is  being  withdrawn.  If  secondary  dyspnoea  supervenes  at  any  time, 
the  tube  should  be  removed  and  a  larger  one  substituted." 


696 


OPERATIVE   SURGERY. 


Fig.  873. — The  operation  of  intubation.  Elevating  epi- 
glottis and  drawing  tongue  forward  with  finger,  direct- 
ing tube  into  larynx.     String  in  tube. 


The  late  Dr.  O'Dwyer  recommended  that  preliminary  practice  in  the 
introduction  and  removal  of  the  tube,  and  touching  of  the  j)arts,  be  had  upon 
the  cadaver  when  j)ossible.     The  removal  of  the  tube  is  more  difficult  than 

the  introduction,  on  ac- 
count of  the  trouble  of 
inserting  the  blades  of 
the  extractor  into  the 
open  upper  end  of  the 
tube  while  more  or  less 
completely  hidden  from 
view  by  the  natural  posi- 
tion of  the  surrounding 
soft  parts.  This  part  of 
the  ojDeration  becomes 
especially  troublesome 
when  the  patient  offers 
any  opposition  to  the 
attempt,  and  it  may 
become  necessary  under 
these  circumstances  to 
administer  an  anesthet- 
ic before  the  tube  can 
be  safely  removed.  The 
occurrence  of  spasm  during  this  time  may  be  met  by  holding  the  finger  in 
place  until  the  irritation  subsides. 

The  Precautions. — It  is  often  wise  in  intubation  to  prepare  for  trache- 
otomy (Fig.  864),  as  efforts  at 
intubation  may  not  succeed. 
Do  not  remove  the  loop  until 
quiet  breathing  has  continued 
for  half  an  hour  or  so,  and  do 
not  permit  the  patient  to  grasp 
it.  The  introduction  of  the 
tube  is  rarely  attended  with 
asphyxia  due  to  detachment 
downward  of  the  membrane, 
and  then,  if  the  patient  be 
caused  to  cough  as  the  tube  is 
quickly  withdrawn,  the  mem- 
brane is  usually  expelled.  Fail- 
ing in  this,  tracheotomy  for- 
ceps may  be  tried  for  removal 
of  the  membrane,  which,  if  in- 
efEective,  is  followed  at  once  by 
tracheotomy.      Three   or   four 

per  cent  only  require  the  latter  measure  of  relief.     The  tube  may  be  passed 
into  the  oesophagus  and  possibly  enter  the  trachea.     The  evidences  of  par- 


FiG.  874. — The  operation  of  intubation.    Tube 
passing  under  end  of  finger. 


OPERATIONS   ON  THE   NECK. 


697 


Fig.  875. — The  operation  of  intubation.    The  tube  pressed 
into  place  witli  the  finger  and  detached  from  obturator. 


tially  detached  membrane  in  the  trachea  call  for  prompt  removal  of  the 
tube.     Inversion  of  the  patient  and  striking  of  the  body  by  the  attendants 

may  cause  the  tube  to  be 
expelled  along  with  the 
obstructing  membrane 
and  rescue  the  patient 
without  the  dangers  of 
delay.  The  not  infre- 
quent occurrence  of  se- 
vere and  perhaps  fatal 
dyspnoea,  following  re- 
moval of  the  tube,  enjoins 
close  attention  to  the  pa- 
tient for  an  hour  or  so 
thereafter. 

The  RemarJi-s. — In  the 
adult  the  tube  can  be  in- 
troduced by  aid  of  a  mir- 
ror, especially  when  the 
throat  is  accustomed  to 
the  use.  It  is  wise  for 
the  operator  to  give  some  little  amount  of  time  to  practicing  in  introducing 
the  tube.  The  extracting  of  the  tube  from  the  clinched  hand  will  offer  in 
a  degree  the  needed  opportunity  for  this  kind  of  practice.  Should  the  tube 
happen  to  slip  below  the  vocal 
cords  it  will  no  doubt  be  ar- 
rested by  the  cricoid  cartilage, 
and  only  by  division  of  the 
latter  can  the  tube  be  with- 
drawn from  below. 

The    After  -  treatment 
Quiet,  support,  and  cleanliness 
are  indicated.    Carey  and  Cas- 
selherry  have  recorded  the  im- 
portant fact  that 
with     the     head 
lower     than     the 
shoulders        food 
can  be  swallowed 
quite  readily  with 
the  tube  in  place 
without        much 
trouble.      Highly 
nutritious      fluid 
foods     are     com- 
monly employed  in  these  cases.     Usually  the  tube  is  removed  in  four  or 
five  days  and  not  reintroduced  thereafter  without  special  indications. 


Fig.  876. — The  operation  of  intubation.     The  tube 
held  in  place  by  finger  wliile  string  is  withdrawn. 


698  OPERATIVE  SURGERY. 

The  Results. — McNaughton  and  Maddern  reported  5,546  cases  of  intu- 
bation with  69.5  per  cent  mortality  without  the  use  of  antitoxine.  Five 
hundred  and  thirty-three  cases  with  the  use  of  antitoxine  gave  25.9  per  cent 
mortality.     With  the  use  of  antitoxine — 


Cases. 

Recoveries. 

Brown  reports 

2,368 

1,445 

73 

30 

647 

Ranke  reports 

558 

McNaughton  reports 

88 

O'Dwver  reports 

10 

Waxliam  reports  543  cases  of  intubation  in  private  practice  with  39.39 
per  cent  recoveries. 

It  is  quite  apparent  that  intubation  is  followed  by  a  higher  rate  of  recov- 
ery than  is  tracheotomy,  and  that  the  administration  of  antitoxine  increases 
the  efficiency  of  intubation  in  an  astonishing  degree. 

Foreign  Bodies  in  the  Air  Passages. — Foreign  bodies  invade  the  air  pas- 
sages, and  in  many  instances  cause  alarming  symptoms  followed  by  a  rapid 
and  fatal  outcome.  The  larynx,  trachea,  and  bronchi  are  the  common  sites 
of  invasion,  and  demand  the  exercise  of  discreet  though  prompt  and  efficient 
action  for  relief.  A  knowledge  of  the  nature  of  the  foreign  body  is  of  great 
importance,  as  bearing  on  the  ease  of  removal  and  the  kind  of  tissue  changes 
induced  by  its  presence.  The  surroundings  of  the  patient  have  much  to  do 
with  determining  the  nature  of  these  bodies.  However,  corn,  beans,  various 
seeds,  and  small  toys  make  up  a  large  proportion  of  these  offending  agents. 
Seeds  increase  in  size  naturally  from  the  absorption  of  moisture,  and  become 
therefore  more  difficult  of  removal  as  time  advances.  Organic  agents  of 
infective  character  are  especially  dangerous  because  of  the  tissue  changes 
which  they  incite.  Inorganic  substances  are  the  least  objectionable  unless 
endowed  with  some  special  destructive  nature.  The  employment  of  the 
X  rays  are  especially  serviceable  in  determiniug  the  location  and  nature  of 
the  object. 

The  invasio?i  of  the  larynx  by  a  foreign  body,  attended  with  symptoms 
of  pronounced  character,  calls  for  a  prompt  examination  of  the  throat  and 
larynx  with  the  finger,  and  unless  relief  be  thus  promptly  afforded,  laryn- 
gotomy  in  the  adult  and  tracheotomy  in  the  child  should  be  performed  'at 
once.  When  the  symptoms  are  not  urgent,  a  more  deliberate  course  can  be 
followed,  fortified  by  the  knowledge  gained  by  the  use  of  the  laryngoscope, 
fluoroscope,  and  other  methods  of  inquiry.  And,  too,  the  removal  may  be 
deliberately  conducted  with  approved  instruments,  and  operative  procedures 
directed  to  opening  the  larynx  above,  through,  or  below  the  thyroid  carti- 
lage, according  to  the  situation  of  the  foreign  body,  utilizing  by  this  route 
the  best  channel  for  removal. 

The  invasion  of  the  trachea  by  a  foreign  body  calls  for  a  prompt  low 
tracheotomy,  which  should  be  done,  if  possible,  before  the  fixation  of  the 
foreign  body  in  a  bronchus  takes  place.  The  opening  should  be  free  to 
admit  of  prompt  escape  of  the  offending  agent  with  the  act  of  coughing. 
If  the  foreign  body  have  become  fixed  already,  dislodgment  should  be  at- 


OPERATIONS  ON  THE  NECK.  699 

tempted  with  a  probe  or  feather,  while  the  tracheal  opening  is  held  widely 
apart  to  facilitate  the  escape.  Inversion  of  the  patient,  thumping  on  the 
back,  etc.,  are  practiced  after  tracheotomy  is  performed.  In  the  interval  of 
the  attempts  at  removal  the  borders  of  the  tracheal  wound  should  be  held 
widely  apart  with  traction  sutures  carried  through  each  border  around  the 
neck  and  tied  behind. 

The  invasion  of  a  bronchus  by,  and  final  fixation  there,  of  a  foreign  body, 
while  not  immediately  dangerous,  exposes  the  patient  to  many  problematical 
contingencies  of  a  fatal  nature.  The  foreign  body  may  block  the  entire 
right  or  left  bronchus,  or  one  or  more  subdivisions  of  the  same,  singly  or 
simultaneously,  according  to  its  size.  The  right  bronchus  is  involved  more 
frequently  than  the  left,  the  proportion  being  three  of  the  former  to  two  of 
the  latter. 

The  Treatment. — In  the  instance  of  seed  impaction,  a  policy  of  conser- 
vatism is  usually  the  wiser  one. 

Inversion  and  thumping  on  the  back  can  be  practiced  without  trache- 
otomy when  the  object  is  known  to  be  of  so  small  a  size  as  to  readily  escape 
through  the  rima  glottidis.  However,  if  the  object  be  a  large  one  or  of 
uncertain  size,  or  the  case  one  which  has  been  attended  already  by  violent 
efforts  at  expulsion,  then  tracheotomy  and  wide  separation  of  the  tracheal 
opening  should  always  precede  any  effort  at  dislodgment. 

Direct  dislodgment  is  practiced  with  forceps,  probes,  bent  wire,  blunt 
hooks,  suction  by  a  rubber  tube  attached  to  Bigelow's  litholopaxy  pump, 
corkscrew  apparatus,  etc.  The  stereotyped  and  extemporized  implements 
and  means  for  extraction  are  numerous,  but  favorable  outcome  does  not 
keep  pace  with  ingenuous  though  often  unwise  instrumentation.  In  gen- 
eral terms  the  following  plan  of  interference  is  commended  :  Locate  the 
site  of  the  impacted  obstruction  by  auscultation,  etc. ;  perform  a  free,  low 
tracheotomy,  and  hold  the  borders  of  the  tracheal  wound  widely  asunder 
with  traction  sutures ;  introduce  a  flexible  probe,  and  locate  the  obstruction 
and  dislodge  it  if  possible ;  failing  in  this,  try  forceps  of  proper  size  and 
shape,  or  a  wire  with  a  hooked  extremity,  or  fine  silver  wire  looped  and 
passed  beyond  the  obstructing  agent  and  withdrawn.  The  patient  should 
be  under  an  anaesthetic  during  the  attempts,  otherwise  the  spasmodic  cough, 
due  to  the  irritation  of  the  manipulation,  will  defeat  careful  effort  and  per- 
haps cause  avoidable  disaster.  It  may  be  advisable  to  open  the  thorax  pos- 
teriorly to  effect  relief  (page  1288). 

The  Comments. — When  tracheotomy  is  followed  by  entire  relief  from 
dyspnoea,  the  foreign  body  is  either  in  the  larynx  or  occupies  a  small  tube. 
The  presence  of  a  foreign  body  in  the  bronchus  is  not  an  absolute  indication 
for  operation,  as  circumstances  may  contraindicate  it.  When  the  obstruc- 
tion can  be  located,  a  low  tracheotomy  is  justifiable  with  brief,  cautious 
attempts  at  extraction. 

The  question  of  tracheotomy  will  depend  largely  upon  the  form,  size, 
and  character  of  the  foreign  body.  Not  more  than  three  attempts  of  a 
minute  each  should  be  employed  with  forceps  to  remove  a  foreign  body 
(Gross). 

45** 


700  OPERATIVE  SURGERY. 

"  Low  tracheotomy  is  advisable  when  the  presence  of  a  foreign  body  is 
certain ;  it  adds  but  little  to  the  risk  and  affords  easier  escape  for  the  object, 
even  when  extraction  is  not  feasible. 

"  Subsequent  dangers  arise  from  severe  and  prolonged  instrumentation, 
not  from  tracheotomy.  Voluntary  expulsion  is  more  probable  after  than 
before  tracheotomy. 

"  The  risks  of  thoracotomy  and  bronchotomy,  following  unsuccessful  tra- 
cheotomy, are  greater  than  the  dangers  incurred  by  permitting  the  foreign 
body  to  remain"  (Willard). 

The  Results. —  Voluntary  expulsion  is  not  an  uncommon  occurrence, 
happening  within  a  few  hours,  or  after  weeks'  and  even  years'  delay.  Nearly 
90  per  cent  will  recover  without  operative  interference  (Weist). 

"  When  a  foreign  body  becomes  impacted  in  the  bronchus,  extraction 
is  an  impossibility  in  78  per  cent  of  the  cases  even  after  tracheotomy" 
(Willard). 

The  employment  of  instruments  increases  the  death  rate  from  pneu- 
monia 12  per  cent.  Smith  reports  in  1,600  cases  a  70-per-cent  rate  of 
recovery  in  the  non- operative  and  76  per  cent  in  operative  cases.  Dunham 
reports  50  per  cent  recoveries  in  non-operative  and  77  per  cent  in  operative 
cases. 

Guyon  and  Dunham  in  1,674  cases  report  70  per  cent  recoveries  in  non- 
operative  and  75  per  cent  in  operative  cases.  About  10  per  cent  die  from 
the  operation  only. 

Laryngectomy. — Laryngectomy  is  a  serious  operation  and  is  not  practiced 
except  for  the  cure  of  malignant  disease.  It  consists  in  the  removal  of  a 
part  or  the  whole  of  the  larynx,  and  is  classified,  therefore,  as  the  complete 
and  incomplete  varieties. 

Complete  Laryngectomy. — If  the  neck  be  not  too  short  for  the  purpose, 
as  may  be  the  case  in  emphysematous  patients,  a  preliminary  tracheotomy 
should  be  performed  several  days  in  advance  of  the  major  operation,  to 
accustom  the  pulmonary  tissues  of  the  patient  the  sooner  to  the  influences 
of  the  abnormal  respiratory  channel.  If  the  neck  be  too  short  for  the  utiliza- 
tion of  this  preparatory  step,  the  cannula  may  be  introduced  during  the  course 
of  the  operation  (Kocher).  After  the  patient  is  anaesthetized, the  trachea  should 
be  plugged  by  the  use  of  the  Trendelenburg  or  the  Hahn  sponge  tampon 
cannula  (Figs.  878  and  879),  being  certain  that  the  rubber  tampon  is  new 
and  that  it  be  slowly  distended  into  the  proper  position.  The  ordinary 
cannula,  supplemented  by  sponge  packing,  is  employed  with  entire  satis- 
faction by  many  surgeons. 

The  Operation  (Kocher). — Place  the  patient  on  the  back  with  the  shoul- 
ders raised  and  the  head  extended  over  a  padded  bottle  or  sandbag;  make 
an  incision  in  the  median  line  from  the  hyoid  bone  downward  to  a  point 
an  inch  and  a  quarter  below  the  cricoid  cartilage,  exposing  the  thyroid  and 
cricoid  cartilages  and  the  upper  border  of  the  isthmus  of  the  thyroid  body ; 
divide  the  suspensory  ligament  of  the  isthmus  at  the  lower  border  of  the 
cricoid;  separate  the  isthmus  and  its  associated  transverse  veins  from  the 
trachea  and  push  them  downward  with  a  blunt  dissector;  divide  the  cricoid 


OPERATIONS  ON  THE  NECK.  701 

and  upper  rings  of  the  trachea  in  the  median  line,  forcing  the  isthmus 
downward  and  even  dividing  it  between  two  ligatures  in  the  median  line  if 
sufficient  room  can  not  be  otherwise  gained  ;  introduce  the  tampon  cannula  ; 
make  a  transverse  incision  through  the  skin  and  fascia  along  the  hyoid 
bone,  ligaturing  the  anterior  jugular  veins;  divide  the  sterno-hyoid,  the 
omo-hyoid,  and  thyro-hyoid  muscles  close  to  the  hyoid  bone,  at  their  inser- 
tions ;  draw  the  hyoid  bone  up  with  a  strong,  sharp  hook  ;  divide  transversely 
the  portion  of  the  thyro-hyoid  membrane  attached  to  the  middle  part  of  the 
hyoid  bone ;  divide  also  the  subjacent  mucous  membrane  and  seize  the  epi- 
glottis at  its  upper  part  with  a  sharp  hook  and  draw  it  forward ;  slit  the 
epiglottis  medianly  if  healthy,  if  unhealthy  cut  round  it  beyond  the  diseased 
tissue ;  split  the  thyroid  cartilage  at  the  middle  downward  to  the  tracheal 
wound ;  arrest  hasmorrhage  at  the  wound  edges  and  paint  them  with  a  ten- 
per-cent  solution  of  cocain  to  obviate  the  coughing  and  swallowing  reflexes ; 
define  the  limits  of  the  new  growth  and  divide  the  tissues  beyond  them ; 
divide  the  mucous  membrane  with  the  thermo-cautery.  If  the  whole  larynx 
be  diseased,  divide  the  mucous  membrane  along  the  epiglottis,  arytenoid  car- 
tilages, the  larynx  or  trachea,  to  below  the  tumor ;  expose  the  outer  surface 
of  the  larynx,  preserving  the  muscles  in  so  far  as  is  consistent  with  the 
removal  of  diseased  tissue  ;  expose  the  cartilages  and  remove  them  partially 
or  entirely,  according  to  the  extent  of  the  disease ;  retain  the  healthy  and 
movable  mucous  membranes  at  the  posterior  surface  of  the  cricoid  cartilage  ; 
continue  downward  the  dissection  to  the  lower  limit  of  the  disease,  dividing 
the  healthy  cricoid  or  trachea  transversely ;  sew  upward  as  far  as  possible  the 
anterior  wall  of  the  oesophagus  and  pharynx  to  re-establish  the  septum 
between  the  respiratory  and  alimentary  passages  (page  709). 

The  After-treatment. — Substitute  a  simple  cannula  for  the  tampon 
cannula.  Introduce  no  sutures,  but  stuff  the  cavity  with  carbolic  gauze 
which  is  changed  every  two  hours.  Feed  the  patient  through  an  oesophageal 
tube  and  get  him  out  of  bed  as  soon  as  possible. 

The  Results. — But  1  case  in  12  died  from  this  plan  of  operation. 

Treves's  Method. — The  following  succinct  plan  of  procedure  is  intro- 
duced from  Treves's  Operative  Surgery: 

"  The  Operation. — The  patient  lies  upon  the  back,  close  to  the  right 
border  of  the  table.  The  shoulders  are  raised,  and  the  head  is  well  extended 
over  a  hard  cushion  or  sandbag.  The  surgeon  stands  on  the  patient's  right. 
The  chief  assistant  takes  his  place  at  the  head  of  the  couch,  and  close 
to  the  surgeon's  left.  An  incision  is  made  in  the  median  line  from  the 
center  of  the  thyro-hyoid  membrane  to  the  second  or  third  ring  of  the 
trachea.  At  the  upper  end  of  this  incision  a  transverse  cut  is  made  which 
is  carried  outward  on  either  side  sufficiently  far  to  reach  the  sterno-mastoid 
muscles. 

"The  flaps  thus  marked  out  are  turned  back.  Some  division  of  the 
fibers  of  the  sterno-mastoid  muscles  may  be  necessary.  The  vertical  incision 
should  go  down  to  the  thyroid  and  cricoid  cartilages  and  the  trachea. 

"  The  superior  thyroid  arteries  may,  if  thought  fit,  be  dealt  with  at  this 
stage.     They  should  be  secured  by  two  ligatures,  and  then  divided  between 


Y02  OPERATIVE  SURGERY. 

them.  The  vessels  would  be  sought  for  at  the  posterior  margin  of  the  thyro- 
hyoid muscle,  close  to  the  upper  border  of  the  thyroid  cartilage. 

"  The  inferior  thyroid  arteries  may  be  exposed  and  dealt  with  in  the  same 
manner  as  they  turn  forward  at  the  lower  margin  of  the  larynx.  They  should 
be  sought  for  beneath  the  posterior  edge  of  the  sterno-thyroid  muscle. 

"  The  fascia  having  been  well  divided  in  the  middle  line,  a  broad  perios- 
teal elevator  or  a  rugine  is  introduced,  and  by  means  of  it  the  soft  parts  can 
be  separated  from  the  laryngeal  cartilages  without  employing  the  knife. 

"  The  crico-thyroid,  sterno-thyroid,  and  thyro-hyoid  muscles  are  detached 
on  one  side,  and  are,  together  with  the  other  soft  parts,  held  with  a  retractor 
while  the  larynx  is  drawn  over  to  the  other  side  by  means  of  a  sharp  double 
hook.  The  attachment  of  the  inferior  constrictor  muscle  to  the  thyroid 
cartilage  can  now  be  severed,  partly  by  detachment  with  the  elevator  or 
rugine,  and  partly  by  cutting  it  with  curved,  blunt-pointed  scissors,  which 
are  kept  very  close  to  the  cartilage.  The  larynx  is  now  pulled  forward  as 
well  as  to  the  opposite  side,  and  the  tissues  are  divided  about  the  gap  which 
intervenes  between  the  cut  and  now  separated  ends  of  the  superior  thyroid 
artery.  The  superior  laryngeal  nerve  is  also  now  divided.  The  thyroid 
gland  is  pushed  aside  with  the  soft  parts. 

"  If  the  larynx  be  now  well  drawn  over  to  the  other  side,  the  other  half 
of  the  organ  can  be  stripped  of  its  coverings  in  precisely  the  same  manner. 

"  The  next  step  is  to  divide  the  thyro-hyoid  ligaments  and  membrane, 
and  to  cut  the  extralaryngeal  connections  of  the  epiglottis.  This  structure 
may  be  conveniently  drawn  forward  while  its  attachments  are  being  freed. 

"  The  entire  larynx  is  now  pulled  forward  by  means  of  sharp  hooks 
introduced  into  its  upper  part,  and  the  organ  is  separated  from  its  remaining 
connections  with  the  pharynx  and  oesophagus — at  first  laterally,  and  then 
from  above  downward. 

"  If  proper  care  be  taken,  the  oesophagus  should  be  nowhere  '  button- 
holed.' Special  care  is  required  to  separate  the  cricoid  cartilage  from  the 
commencement  of  the  gullet, 

"  The  trachea  is  now  secured  (unless  already  adherent)  by  means  of  two 
ligatures,  which  are  held  by  an  assistant,  and  the  excision  is  completed  by 
dividing  the  membrane  between  the  cricoid  cartilage  and  the  trachea  from 
behind  forward. 

"  One  or  more  rings  of  the  trachea  may  be  removed  at  the  same  time  if 
it  be  considered  necessary. 

"  The  upper  end  of  the  divided  trachea,  which  has  been  prevented  from 
slipping  down  by  the  two  ligatures,  is  now  secured  to  the  integument  by 
several  points  of  interrupted  suture. 

"  Three  or  four  deep  sutures  of  silver  wire  are  passed  beneath  the  upper- 
most ring,  and  are  made  to  attach  the  windpipe  securely  to  the  skin ;  a 
further  series  of  fine  superficial  sutures  unite  the  mucous  membrane  of  the 
trachea  to  the  cut  margin  of  the  skin. 

"  The  bleeding  throughout  the  operation  will  be  free,  and  each  small 
vessel  should  be  ligatured  as  soon  as  it  is  divided.  The  limited  space  does 
not  favor  the  use  of  many  pressure  forceps." 


OPERATIONS  ON   THE  NECK.  703 

It  often  happens  that  in  addition  to  the  hirynx  the  hyoid  bone,  base  of 
the  tongue,  pharynx,  and  oesophagus  are  involved  in  a  malignant  growth. 
If  operation  be  attempted,  under  these  circumstances,  the  first  step  is  to  intro- 
duce the  tampon  cannula  of  Trendelenburg,  or  a  substitute,  through  which 
the  ana3sthetic  is  administered.  Then  make  a  transverse  incision  through 
the  skin  from  the  inner  edge  of  one  sterno-mastoid  muscle  to  the  other, 
passing  half  an  inch  above  the  hyoid  bone ;  from  this  carry  a  second  one 
vertically  downward  along  the  median  line  of  the  trachea  to  the  incision 
made  to  open  the  trachea ;  turn  the  flaps  outward ;  remove  all  large  glands 
in  the  vicinity ;  divide  the  muscular  attachments  to  the  hyoid  bone  ;  tie  the 
lingual  and  superior  thyroid  arteries ;  excise  the  tongue  below  the  disease, 
along  with  the  palato-pharyngeal  arches,  if  necessary,  carefully  avoiding  the 
external  carotid  arteries  when  it  is  possible ;  if  not  possible,  draw  them  for- 
ward along  with  the  pharynx  and  divide  them  between  two  ligatures ;  cut 
the  lingual  and  hypoglossal  nerves.  The  larynx  is  now  separated  from  the 
trachea  by  cutting  the  latter  just  below  the  cricoid  cartilage ;  a  cannula  is 
introduced  into  it,  the  parts  are  thoroughly  washed  with  a  carbolized  solu- 
tion, the  flaps  placed  in  contact  with  the  raw  surfaces  without  sutures,  and 
the  wound  sprinkled  with  iodoform.  If  the  oesophagus  be  divided,  its  lower 
extremity  must  be  kept  open  and  so  placed  that  it  can  be  protected  from 
the  entrance  of  discharges,  and  become  an  available  channel  through  which 
to  nourish  the  patient. 

Partial  Laryngectomy. — Partial  laryngectomy  is  practiced  when  the  lim- 
ited extent  of  the  disease  does  not  require  the  removal  of  the  entire  organ. 
Half  of  the  larynx,  or  half  of  the  thyroid  cartilage,  with  or  without  the 
cricoid,  may  be  removed.  Inasmuch  as  the  same  dangers  are  incurred  as  in 
the  complete  operation,  although  in  a  lesser  degree  in  some  respects,  similar 
means  of  prevention  are  necessarily  employed.  The  incisions  relate  only 
to  the  afl^ected  side.  The  organ  is  split  in  the  median  line  and  the  cavity 
examined.  The  thyroid  cartilage  is  carefully  removed  (page  700),  cautiously 
avoiding  injury  of  the  pharynx.  The  associated  membranes  are  divided  as 
closely  as  practicable  to  the  cartilage.  The  superior  cornu  of  the  cartilage 
is  removed  with  strong  scissors  or  pliers.  The  epiglottis  is  usually  left 
entire,  and  the  aryteno-epiglottidean  fold  of  the  diseased  side  is  divided 
close  to  the  cuneiform  cartilage. 

The  Precautions. — Prompt  arrest  of  hemorrhage,  close  hugging  of  the 
cartilage  during  removal,  careful  avoidance  of  injury  to  the  oesophagus, 
complete  asepsis,  and  the  prevention  of  pulmonary  infection  are  the  impor- 
tant features  of  the  operation. 

The  Remarks. — The  tampon  cannula  and  the  tracheotomy  tube  are  used 
the  same  (if  at  all)  as  in  the  complete  operation,  except  that  they  are  em- 
ployed for  a  briefer  period.  The  cricoid  cartilage  may  be  removed  entire,  or 
half  only  may  be  taken  away  along  with  the  thyroid.  The  fact  that  cancer 
slowly  involves  the  cartilage,  causing  localized  death,  unattended  by  much 
infiltration,  suggests  the  practice  of  removal  of  circumscribed  disease  by  cut- 
ting and  scraping,  even  when  the  cartilage  is  superficially  involved.  We  are 
not  disposed  to  regard  with  favor  treatments  of  this  kind,  unless  for  some 


704  OPERATIVE  SURGERY. 

special  reason,  and  then  only  when  a  strict  monthly  surveillance  can  be 
exercised  to  note  any  evidences  of  return.  The  after-treatment  is  not  un- 
like that  of  the  complete  operation,  but  is  less  extended  because  of  the  less 
profound  nature  of  the  wound. 

The  Results. — The  death  rate  of  partial  removal  is  lower  than  is  that  of 
complete  removal.  The  rate  of  final  cure  is  somewhat  less  in  the  former 
than  in  the  latter  method  of  practice. 

The  General  Remarks. — An  ordinary  tracheotomy  tube  can  be  fortified 
with  a  sponge  confined  in  place  around  the  tube  with  thread,  so  that  when 
wet  it  will  occlude  the  trachea.  Gusseniauer  regards  high  tracheotomy  as 
a  legitimate  part  of  the  procedure  and  performs  it  as  an  initial  step. 
Splitting  of  the  larynx  enables  one  to  determine  the  extent  of  the  disease, 
and  perhaps  save  a  part  of  the  organ.  There  appears  to  be  no  good  reason 
why  the  epiglottis  and  cricoid  cartilage  should  be  saved  even  though  not 
diseased  and  their  presence  is  sometimes  objectionable.  Enlarged  cervical 
glands  should  be  sought  for  and  removed.  Malignant  involvement  of  the 
soft  parts  outside  the  larynx  contraindicates  operation.  Only  the  trans- 
verse skin  incisions  are  sewed.  The  wound  is  stuffed  with  gauze,  which  is 
changed  every  eight  hours  or  so.  The  tampon  cannula  is  usually  removed 
and  the  tracheotomy  tube  substituted  after  two  or  three  days.  However, 
some  surgeons  employ  the  former  much  longer — ten  or  twelve  days.  Treves 
advises  that  a  rubber  tube  be  introduced  into  the  stomach  through  the 
oesophagus,  and  fastened  there  for  four  or  five  days,  and  even  longer,  for 
alimentary  purposes.  In  171  cases  preliminary  tracheotomy  was  omitted  in 
but  8.  The  tissues  should  not  be  bruised  or  torn  during  their  separation 
from  the  larynx,  but  instead  should  be  clean  cut.  Therefore,  suitable  room 
for  observation  and  treatment  should  be  secured  by  judicious  division  of 
restraining  tissues.  Complete  arrest  of  bleeding  is  necessary  before  opening 
the  air  passages,  especially  if  preliminary  tracheotomy  has  not  been  done. 
Additional  caution  is  requisite  to  prevent  wound  infection  when  the  larynx 
has  been  split  before  removal. 

Keen's  Plan  of  Operation. — Keen^  in  a  recent  address*  on  the  technique 
of  total  laryngectomy,  in  reporting  a  strikingly  successful  case  of  his  own, 
dwelt  especially  on  the  preparatory  and  technical  steps  of  the  operation. 
He  advises  that  thorough  preliminary  disinfection  of  the  mouth,  naso- 
pharynx, and  larynx  with  suitable  antiseptic  solutions  be  frequently  made 
for  two  or  three  days  before  the  operation.  Thorough  and  frequent  use  of 
the  toothbrush  and  the  removal  of  offending  carious  stumps  are  also 
advised.  The  performance  of  tracheotomy  ten  days  or  two  weeks  before 
operation  is  counseled  in  cases  suffering  from  dyspnoea,  and  then  only  for 
improving  the  patient's  condition  and  not  to  prevent  the  entrance  of  blood 
to  the  trachea.  Tracheotomy  immediately  preceding  or  attending  the  opera- 
tion. Keen  does  not  regard  as  essential  in  all  cases,  and  when  thus  practiced 
the  opening  should  be  closed,  if  practicable,  as  soon  as  the  operation  is  com- 
pleted.    He  substitutes  when  advisable  the  Trendelenburg  position  for  the 

*  Transactions  of  the  American  Surgical  Association,  vol.  xvii,  1899. 


OPERATIONS  ON  THE  NECK.  705 

use  of  the  various  tampon  cannulae,  thus  removing  from  the  list  an  agent  of 
hindrance  and  of  special  danger.  Anaesthetics  are  administered  through  the 
mouth  until  the  air  passage  is  opened,  when  a  large  tracheotomy  tube  is 
introduced,  through  which  anaesthesia  is  continued.  The  patient's  head  is 
kept  low  for  a  day  following  the  operation  by  raising  the  foot  of  the  bed. 
On  the  second  day  the  horizontal,  on  the  third  day  the  sitting  posture,  and 
on  the  fourth  out-of-bed,  respectively,  is  advised.  Nutritive  enemata  are 
given  for  two  days,  followed  by  a  teaspoonful  of  liquid  food  every  half 
hour  by  the  mouth,  washed  down  by  a  tablespoonful  of  sterile  water.  At  the 
end  of  a  week  the  amount  is  much  increased,  solid  food  being  taken  after 
the  tenth  day.  In  the  reported  case  the  patient  could  swallow  from  the  first 
without  instrumental  aid.  Also  in  this  case  the  gauze  drain  was  removed  on 
the  following  day,  half  of  the  stitches  on  the  fourth,  and  the  remainder  on 
the  sixth  day  after  the  operation.  In  the  case  in  question  the  total  extirpa- 
tion followed  about  four  and  a  half  months  after  a  thyrotomy  performed  for 
cure  of  an  intralaryngeal  malignant  growth.  The  patient  was  placed  in  the 
Trendelenburg  position  and  a  median  incision  was  made  along  the  scar  of 
the  previous  operation.  The  thyroid  cartilage  was  split  in  halves,  the  bor- 
ders were  drawn  apart  to  determine  the  extent  of  the  disease,  and  thereby 
also  that  of  the  proposed  operation.  The  soft  parts  were  dissected  away  from 
the  sides  of  the  larynx,  the  median  incision  was  carried  down  nearly  to  the 
sternum,  the  trachea  exposed,  a  low  tracheotomy  done,  an  ordinary  large 
tracheotomy  tube  introduced,  the  inner  tube  then  removed,  and  the  chloro- 
form apparatus  connected  with  the  central  tube  by  means  of  the  metal  tube 
of  Hahn's  cannula.  The  trachea  was  then  divided  across  below  the  thyroid 
cartilage,  the  lower  end  of  the  larynx  drawn  forward  and  upward  by  means 
of  a  hook  and  the  finger,  and  the  posterior  surface  of  the  organ  was  separated 
from  the  oesophagus  by  means  of  the  finger  and  Allis's  blunt  dissector  as  far 
as  the  upper  border,  when  the  attachments  to  this  portion  were  divided  with 
scissors  and  the  larynx  was  removed.  The  epiglottis  was  also  removed. 
"  The  upper  edge  of  the  anterior  wall  of  the  pharynx  was  then  carefully 
attached  to  the  tissues  just  below  the  hyoid  bone  by  interrupted  silk  sutures 
placed  very  close  together,"  thus  shutting  off  the  secretions  of  the  pharynx 
and  mouth  from  the  wound.  The  upper  end  of  the  trachea  was  united  to 
the  skin  by  silk  sutures,  the  tube  removed,  and  the  tracheotomy  wound 
closed  by  suturing  the  rings  with  catgut,  and  the  remaining  tissues  of  the 
wound  by  silkworm-gut  sutures.  The  wound  above  the  exposed  end  of  the 
trachea  was  closed  by  silkworm-gut  sutures  and  a  small  gauze  drain  inserted 
at  its  lower  portion.  Narrow  strips  of  folded  gauze  were  laid  above  and 
below  the  exposed  end  of  the  trachea,  which  was  then  protected  by  placing 
over  it  a  sterilized  wooden  pill  box  without  bottom  or  top,  covered  with  two 
or  three  layers  of  gauze  properly  fastened  to  the  contiguous  dressing.  The 
pill  box  and  gauze  were  removed  from  time  to  time  for  the  purposes  of 
cleanliness.  The  wound  healed  at  once  throughout  and  the  patient  made  a 
prompt,  complete,  and  uneventful  recovery. 

The  Remarks. — After  four  days  the  occasional  introduction  of  the  tube 
was  advisable  to  counteract  the  tendency  to  closure  of  the  open  end,  because 


706 


OPERATIVE  SURGERY. 


of  contraction,  and  to  the  inturning  of  the  integumentary  borders.  As 
ah-eady  indicated  at  the  beginning,  the  stitches  should  be  removed  as  promptly 
as  possible.  In  indicating  briefly  the  future  technique  in  a  similar  case, 
Keen  says :  "  In  my  next  case,  after  dissecting  the  soft  parts  from  the  larynx 
and  upper  trachea  back  to  the  oesophagus  on  both  sides,  I  shall  place  the 
patient  in  the  Trendelenburg  position  and  deepen  the  narcosis  to  a  slight 
extent.  I  shall  then  divide  the  trachea  transversely,  and  by  three  sutures, 
one  in  the  middle  line  and  one  on  each  side,  shall  quickly  attach  the  tracheal 
stump  to  the  skin.  Then  I  shall  introduce  the  ordinary  tracheotomy  tube 
into  the  open  end  of  the  trachea  instead  of  through  a  tracheotomy  wound, 
and  continue  the  ansesthetic  through  the  tube.  The  later  steps  of  the  opera- 
tion will  be  the  same  as  above  described.  In  order  not  to  embarrass  the 
operator  the  flange  of  the  tracheotomy  tube  should  only  project  at  the  sides, 
as  the  usual  wide  upper  border  of  the  flange  would  interfere  with  access  to 
the  parts  at  the  beginning  of  the  removal  of  the  larynx." 

The  plan  of  action  expressed  and  practiced  by  Keen  reduces  the  danger 
from  infection  to  a  minimum  and  shortens  the  time  of  operation.  In  suitable 
cases,  and  in  the  hands  of  experienced  operators,  the  arrangement  of  the  details 
will  without  doubt  greatly  improve  the  outcome  in  many  respects.  The 
amount  of  hasmorrhage  is  comparatively  small  in  any  event  if  care  be  exer- 
cised in  the  selection  of  cases  and  in  their  treatment. 
The  utilization  of  the  artificial  larynx  is  prevented  in 
this  method  unless  a  secondary  operation  be  done. 


Fig.  877. — Trendelenburg's  tam- 
pon, a,  b.  Tube  for  inflating 
rubber  bag  (c).     k.  Clamp, 


Fig.  878. — Trendelenburg's  tampon  in  position. 
a.  Bag  for  inflation  of  the  tampon,  b.  Metallic 
funnel  covered  with  flannel  for  anaesthesia. 


Perier  recommends  the  performance  of  laryngectomy  without  pre- 
liminary tracheotomy  through  an  1-shaped  incision  made  from  the  hyoid 
bone  to  below  the  cricoid  cartilage.  The  larynx  is  exposed  laterally,  two 
stout  threads  are  passed  through  the  trachea  at  the  site  of  proposed  divi- 
sion, the  trachea  is  severed,  and  a  special  tube  is  inserted  into  the  open 
end  through  which  anassthesia  is  continued  while  the  operation  is  being 
completed. 

Tamponing"  of  the  Trachea. — Tamponing  the  trachea  calls  for  more  than 
passing  notice  because  of  the  acknowledged,  direct,  and  consequent  dangers 


OPERATIONS  ON  THE  NECK. 


YOT 


Fig.  879.— Tampon  after  Hahn  and 
Michael. 


which  the  act  incurs,  and  also  of  the  growing  tendency  to  ignore  tampon 
cannula  altogether  when  it  is  possible  to  supplement  their  utility  by  postural 
methods.  Tamponing  the  trachea  is  done  to  prevent  the  entrance  of  blood 
to  the  trachea  in  unusual  operations  on  the  larynx,  and  the  oral  and  pharyn- 
geal cavities.  The  methods  most  often  em- 
ployed are  those  of  Trendelenburg  (Figs. 
8T7  and  878),  Hahn  (Fig.  879),  and 
Gerster  (Fig.  880).  The  first  is  provided 
with  a  thin  rubber  bag  so  adjusted  to  the 
tube  that  after  introduction  into  the  tra- 
chea it  can  be  inflated  with  air  by  a  rubber 
bulb.  If  it  is  to  remain  some  time  after 
the  operation,  water  or  glycerin  are  re- 
garded as  more  serviceable  than  air.  In 
the  second,  medicated  sponge  is  substituted 
for  the  rubber  bag.  The  sponge  is  fash- 
ioned of  a  proper  shape  and  thickness,  fastened  around  the  tube  with  thread, 
and  permitted  to  dry.  The  thread  is  then  removed,  leaving  the  sponge 
firmly  fixed  in  place,  which  is  then  covered  with  rubber  tissue  tied  in  posi- 
tion. The  extremity  of  the  tampon  is  introduced  and  the  sponge  moistened 
with  a  solution  of  boric  acid  injected  into  it  through  an  opening  in  the 
tube  by  a  hypodermic  syringe.  The  sponge  swells  and  closes  the  trachea, 
and  may  be  permitted  to  remain  in  place  for  some  time  provided  that  the 
discharges  of  the  wound  do  not  come  in  contact  with  it.  The  third  form 
is  caused  to  fit  the  trachea  by  inflation.  The  mechanism  of  its  adjust- 
ment for  use  is  commendable.  However,  the  objections  to  the  use  of 
these  forms  of  apparatus  is  fast  leading  to  their  abandonment  when  pos- 
sible. The  rings  of  the  trachea  have  sustained  severe  injury  from  their 
introduction  and  from  pressure  necrosis.  The  failure  to  projjerly  close 
the  trachea  and  the  liability  of  the  rubber  to  rupture  have  been  followed  by 

annoying  complications 
from  ha?morrhage.      A 
too     great      distention 
may   cause   the   rubber 
tissue    to    balloon    and 
obstruct  the  end  of  the 
tube.      Gerster's   appa- 
ratus  seems   to   afford 
the    most    satisfaction 
of  any.    Each  of  these 
cannula  is  provided  for 
the    adjustment    of    a 
stereotyped   (Fig.   878) 
or   extemporized    (Fig. 
831)  appliance  for  the  administration  of  the  anaesthetic.     The  introduction 
into  the  open  end  of  a  tracheal  stump  of  a  large  ordinary  tracheotomy  tube 
supplemented  by  gauze  packing  around  it  is  a  prompt  and  serviceable 
46 


Fig.  880. — Gerster's  trachea  tampon  cannula. 


fjQS  OPERATIVE   SURGERY. 

method  of  practice.  The  introduction  above  the  tube,  in  low  tracheotomy, 
of  pieces  of  iodoform  gauze  to  arrest  discharges  coming  from  above  are 
regarded  as  beneiicial  in  diphtheria  and  infectious  discharges  from  otlier 
causes. 

The  Artificial  Larynx  (Fig.   881). — Within  four  or  five  weeks   after 

operation,  or  when  the  parts  are  well  healed,  the  artificial  larynx  may  be 

^Hj.  inserted.     At  that  time  competent  author- 

^^B  ity  should  be  consulted  in  order  to  secure 

«lk  Mk/iH^     ^^^®  most  serviceable  apparatus  in  all  re- 

^»,  \y        j^mU^^k,   spects.     In  some   instances   the  artificial 

.^'^"'^^^^^Vn^^^^m  ^^^y^^  gives  but  little  trouble  and  adds 

j^  ^j^^KM^^B   much  comfort  to  the  patient;  in  others  its 

r       ^^l^^^^f'  i  ^^I^^P   ^^®    ^^    ^^^    little    cultivated    and    often 

m      J^  fkjX>^  ^i^    quickly  discarded.   Gussenbauer's  artificial 

■L  .,M  ^  larynx  consists  of  a  long  tracheal  tube  and 

■  I  :■  an  upper  short  speaking  tube.    Wolff's  ap- 

^T^^c.-,  r.  ,  ,  ^.^  •  1  paratus  is  by  some  regarded  more  efficient 
Fig.  881. — Grussenbauer  s  artincial         ),         ,n       <.  a    rri    i  n    ,    i      ■ 

larynx.  than  the  former.    A  T-shaped  tube  is  pre- 

ferred by  some  patients,  although  it  affords 
only  the  lisping  voice.  Methodical  exercise  will  often  enable  a  patient  to 
speak  aloud  without  the  use  of  an  artificial  appliance. 

Tlfie  Precautions. — Exercise  forethought  and  care  to  save  the  mucous 
membrane  of  the  anterior  aspect  of  the  upper  end  of  the  pharynx,  the  pos- 
terior aspect  of  the  larynx,  and  the  epiglottis  itself  (Bardenhauer),  with  the 
idea  of  so  uniting  together  these  various  structures  as  to  eliminate  from 
the  wound,  the  mouth,  the  pharynx,  and  the  oesophagus,  along  with  their 
malign  infective  influences.  If  now  the  divided  muscles  (Eotter)  (depres- 
sors of  the  OS  hyoid)  be  united  over  the  mucous  flaps  the  latter  will  be  cor- 
respondingly strengthened  in  all  respects.  The  utilization  of  skin  flaps 
over  the  muscular  tissue  (Eotter)  adds  greatly  to  the  strength  of  repair 
and  lessens  the  size  of  the  external  wound.  Hartley  emphasizes  the  need 
of  determining  the  presence  of  infected  lymph  nodes  before  operation,  and 
the  hopelessness  of  operation  unless  all  disease  can  be  removed.  The  lymph 
nodes  can  be  practically  divided  into  those  of  the  upper  and  the  lower  dis- 
tricts of  the  larynx.  Those  of  the  upper  are  located  upon  the  thyro-hyoid 
membrane,  near  the  lesser  cornu  of  the  hyoid  bone,  beneath  the  posterior 
belly  of  the  digastric,  upon  the  posterior  border  of  the  thyro-hyoid  muscle 
g,nd  at  the  bifurcation  of  the  carotid  artery.  Those  of  the  lower  are  found 
over  the  crico-thyroid  membrane  and  the  isthmus  of  the  thyroid  gland,  over 
the  crico-thyroid  muscles  and  the  posterior  surface  of  the  lateral  lobes  of 
the  thyroid  gland  and  behind  the  lateral  lobes  and  in  the  interval  between 
the  trachea  and  oesophagus.  These  various  locations  should  be  thoroughly 
examined  for  diseased  nodes  during  operation. 

The  Comments. — Infective  processes  of  the  lungs  and  of  the  cervical 
tissues  are  not  infrequent  causes  of  death  in  this  operation.  With  the 
view  of  obviating  the  former,  local  instead  of  general  anaesthesia  (ether) 
is  now  employed  when  practicable.     Cocain  for  local  effect  on  the  mucous 


OPERATIONS  ON  THE   NECK.  709 

membrane  and  perhaps  l)y  infiltration  (page  40)  (Xuring  operation,  either 
alone  or  supplemented  with  chloroform  or  morphine,  is  commendable  prac- 
tice. The  positions  of  Trendelenburg  and  of  Rose  by  gravitation  prevent 
insufflation  infection  and  render  unimportant  provisional  tracheotomy  and 
the  use  of  the  various  forms  of  tampon  cannulae.  GlilcJc  apparently  secured 
his  gratifying  results  by  eliminating  the  possibility  of  pulmonary  infection 
by  dividing  the  trachea  above  and  then  raising  forward  and  fixing  the 
upper  end  in  the  cervical  wound  before  removing  the  larynx.  The  shutting 
of  the  wound  from  the  mouth  and  pharjmx  is  another  advance  of  decided 
benefit  (see  Precautions).  Gluch  as  well  shut  off  the  mouth  and  pharynx 
from  the  wound,  chiefly  by  means  of  superimposed  skin  flaps  taken  from 
the  neck  and  arranged  after  the  manner  practiced  by  Szymanowsky  for 
cure  of  urethral  fistula  (Fig.  1684).  Free  loosening  of  the  trachea  from 
its  immediate  connections  permitted  Foederle  to  unite  the  end  to  hyoid 
bone  with  sutures.  To  this  may  be  added  the  union  of  the  mucous  mem- 
brane of  the  trachea  to  the  borders  of  the  mucous  membrane  of  the  pos- 
terior aspect  of  the  larynx.  In  this  connection  it  should  be  said  that  gan- 
grene of  the  trachea  from  a  too  free  separation  of  its  connecting  tissue, 
along  with  undue  traction  and  infection,  and  the  giving  way  of  the  union 
between  it  and  the  hyoid  bone  from  too  great  traction,  are  complications 
not  unknown  and  always  to  be  apprehended  in  this  plan  of  treatment.  It 
is  apparent  at  once  that  the  extent  of  the  closure,  as  well  as  the  primary 
location,  will  exercise  great  influence  in  the  selection  of  the  source  of  the 
tissue  for  purposes  of  repair.  The  cricoid  cartillage  should  be  saved  if 
possible. 

The  After-treatment. — The  unclosed  part  of  the  wound  is  packed  with 
gauze  and  the  patient  is  kept  in  bed  without  a  pillow  with  the  foot  of  the 
bed  raised,  thus  favoring  dependant  drainage.  Eectal  nourishment  is 
administered  every  sixth  and  saline  solution  every  third  hour.  On  the  third 
day  the  patient  is  encouraged  to  try  swallowing  small  amounts  of  water, 
which  a  little  later  he  will  do  successfully  provided  the  wound  be  properly 
shut  off  from  the  oro-pharynx.  A  closure  of  the  woiind  by  gentle  external 
digital  pressure  during  the  effort  of  swallowing  (the  same  as  in  oesopha- 
gotomy)  (page  670)  may  effect  the  purpose.  In  case  of  failure  the  use  of 
a  catheter  passed  through  the  nostril  or  the  mouth  may  be  required.  It 
will  not  come  amiss  if  the  patient  be  taught  to  swallow  in  the  Trendelenburg 
posture  before  operation,  for  apparent  reasons. 

The  Results. — The  mortality  of  60  per  cent  of  1881  was  reduced  to 

33  per  cent  in  1895,  as  based  on  309  cases,  of  which  10  per  cent  had  remained 
cured  for  over  three  years  (Powers  and  White).     In  1900,  Gllick  reported 

34  total  operations  for  malignant  diseases  with  a  mortality  of  only  8.5 
per  cent.  Hartley  reports  that  the  death  rate  for  laryngectomies  from 
1886  to  1900  diminished  from  44  per  cent  to  8.5  per  cent,  and  that  the 
remaining  cured  for  over  three  years  increased  from  13  per  cent  to  33  per 
cent  during  that  time.  Regarding  excision  of  the  soft  parts  of  the  larynx 
combined  with  thyreotomy.  Hartley  reports  that  the  permanent  cures  are 
44  per  cent,  with  a  death  rate  of  about  11  per  cent.    This  steady  increase 


YIO  OPERATIVE  SURGERY. 

is  due  to  the  improvement  in  the  technique  especially  relating  to  measures 
directed  to  the  prevention  of  infective  pneumonia  and  cellulitis  of  the  con- 
tiguous cervical  tissue.  It  can  be  safely  said,  we  think,  that  earlier  recog- 
nition of  the  disease  and  prompter  diagnosis  attended  with  urgent  demand 
on  the  part  of  the  medical  attendant  that  the  aid  of  the  surgeon  be  invoked, 
will  add  much  indeed  to  the  present  outcome. 

Estimates  show  a  positive  cure  (three  years  or  more)  of  10  per  cent,  a 
relative  cure  (less  than  three  years)  of  48  per  cent,  and  a  recurrence  of  20 
per  cent  (Schmiegelow). 

Operation  on  the  Thyroid  Body. — An  enlarged  thyroid  body  is  removed 
partially  or  completely,  not  infrequently,  and  otherwise  surgically  treated  to 
afford  relief  from  physical  suffering  and  the  mental  disquietude  which  the 
deformity  due  to  its  presence  causes.  Complete  removal  is  not  practiced 
now  except  for  malignant  disease,  on  account  of  the  unfortunate  sequels  due 
to  its  removal  from  the  human  economy.  At  the  present  time  the  follow- 
ing operative  procedures  are  employed  in  the  surgical  treatment  of  goitre : 
1,  Partial  excision ;  2,  enucleation — resection ;  3,  enucleation ;  4,  ligature  of 
the  arteries  and  exothyropexy.  Complete  excision  is  practiced  in  malignant 
cases  only,  and  with  great  conservatism. 

The  Anatomical  Points. — The  relations  of  the  normal  thyroid  body  to 
the  trachea,  oesophagus,  recurrent  laryngeal  nerves,  and  to  the  carotid  sheath 
and  its  contents,  should  be  given  careful  consideration  before  beginning  the 
operation.  The  shape,  size,  nature,  and  extent  of  the  growth  will  modify  in 
a  marked  degree  its  normal  relations  to  important  structures,  and  have 
much  to  do  to  establish  or  disprove  the  idea  of  operative  action.  The  inferior 
thyroid  arteries  are  larger  than  the  superior,  but  the  anastomosis  between 
them  all  is  of  the  freest  kind.  The  right  superior  thyroid  artery  was  absent 
in  a  case  of  removal  by  the  author.  The  arteria  thyroidea  ima  supplements 
often  the  deficiency  due  to  anomalies  of  the  regular  arterial  supply  of  the 
body.  The  superior  and  inferior  thyroid  veins  are  of  large  size,  are  inti- 
mately associated  with  the  arteries  of  the  same  name,  and  empty  their  blood 
into  the  internal  jugular  and  innominate  veins  respectively.  The  superior 
thyroid  arteries  approach  the  anterior  and  upper  parts  of  the  organ  which 
they  mainly  supply.  The  inferior  lie  below  and  posteriorly  to  the  organ, 
and  supply  chiefly  the  corresponding  portion  of  this  body.  The  recurrent 
laryngeal  nerves  are  closely  and  indefinitely  associated  with  the  inferior 
arteries,  and  for  this  reason  extra  care  is  needed  to  prevent  injury  of  them 
during  ligature  of  these  vessels.  The  sympathetic  nerves  and  the  middle 
cervical  ganglion  are  in  quite  intimate  relations  with  the  inferior  thyroid 
arteries,  and  great  care  should  be  exercised  to  avoid  injury  of  them.  Por- 
tions of  glandular  tissue  of  small  size  and  separated  from  the  main  structiire 
are  found  from  the  arch  of  the  aorta  to  the  hyoid  bone.  These  accessory 
bodies  are  of  much  importance,  as  they  may  become  the  seat  of  carcinoma- 
tous growths.  The  location  of  the  third  lobe  and  its  relation  to  the  isthmus 
and  to  contiguous  structures  should  be  noted.  It  is  sometimes  the  seat  of 
disease,  and  it  is  important  to  know  that  when  healthy  it  often  remains 
behind  in  complete  extirpation  of  the  major  lobes.     The  thyroid  body  is 


OPERATIONS  ON  THE  NECK.  711 

covered  in  front  by  the  stcrno-hyoid,  the  sterno-thyroid,  the  omo-hyoid,  and 
the  anterior  border  of  the  sterno-mastoid  muscles.  It  lies  between  two  lay- 
ers of  fascia  which  unite  above  and  are  attached  to  the  cricoid  cartilage.  A 
distinction  should  be  made  between  the  fascial  covering  and  the  proper  cap- 
sule of  the  thyroid  body,  otherwise  great  confusion  will  attend  the  isolation  of 
the  gland  from  its  contiguous  tissues.  The  atrophy  of  the  tissues  overlying 
the  enlargement  may  be  mistaken  for  the  capsule  of  the  thyroid  body  itself. 

The  Preparation  of  the  Patient. — The  strict  local  aseptic  measures  are 
Ijracticed.  The  bowels  should  be  unloaded  freely  the  day  l^efore  the  opera- 
tion to  obviate  the  need  of  defecation  for  the  first  few  days  afterward. 
Kocher  usually  employs  only  cocain  infiltration  anaesthesia  in  this  operation. 
Chloroform  anaesthesia  (if  general  ansesthesia  be  employed)  is  preferal)le  in 
this  as  in  most  other  operations  at  this  situation.  The  patient  is  placed  on 
the  back,  with  the  shoulders  raised,  and  the  neck  extended  and  well  exposed. 

The  Operation  of  Partial  Excision  (Kocher). — Either  a  transverse  or 
angular  incision  may  be  employed.    If  the  tumor  be  small,  movable,  limited. 


Fig.  882. — The  operation  of  excision  of  goitre  of  the  right  side,  Kocher's  method,  a. 
Branch  of  conimunication  between  anterior  and  external  jugular  veins,  i.  Sterno- 
cleido-mastoid  muscle,  c.  Sterno-thyroid  muscle,  d.  Anterior  jugular  vein.  e. 
Sterno-hyoid  muscle. 

and  of  simple  structure,  and  cosmetic  gain  be  important,  make  a  liberal 
transverse  incision  with  a  slightly  upward  convexity  along  the  line  of  cleav- 
age of  the  skin,  across  the  most  prominent  part  of  the  tumor,  through  the 
integument  and  platysma,  between  the  outer  borders  of  the  sterno-mastoid 
muscles  (Fig.  882),  catching  the  superficial  vessels  and  dividing  them 
between  two  ligatures;  divide  the  fascia  and  expose  the  spread-out  fibers  of 


712 


OPERATIVE  SURGERY. 


the  sterno-laryngeal  and  sterno-mastoid  muscles;  separate  the  former  mus- 
cles in  the  median  line  and  divide  the  subjacent  fascia  upward  and  down- 
ward upon  the  finger;  push  the  muscles  toward  the  larynx  the  requisite 
distance,  incising  the  needed  extent  when  required ;  divide  at  this  time  the 
external  capsule  of  the  tumor  so  as  to  permit  ready  separation  of  the  goitre 
with  a  blunt  instrument. 


Fig.  883. — The  dislocation  of  tlie  goitre. 

The  Dislocation  of  the  Goitre. — Draw  aside  the  muscles  with  retractors; 
introduce  the  finger  underneath  the  incised  capsule  and  the  muscles  and 
carry  it  around  the  tumor,  hooking  forward  the  bands  stretching  between 
the  adjacent  tissues  and  the  tumor;  ligature  and  divide  the  veins  asso- 
ciated with  the  bands,  which 
former  are  often  quite  large,  also 
divide  the  bands  at  the  same 
time;  drag  forward  the  goitre 
with  the  fingers  (Fig.  883), 
thus  affording  relief  from  any 
dyspnoea;  ligature  the  main 
vessels  in  regular  order,  begin- 
ning with  the  superior  thyroid. 
Separate  with  a  blunt  director 
the  capsule  internally  and  ex- 
ternally from  the  upper  cornu, 
forming  a  pedicle  of  the  supe- 
rior thyroid  artery  and  vein 
(Fig.  884),  which  carefully 
divide  between  two  ligatures. 


-:^V 


Fig.  884. — The  ligaturing  of  superior  thyroid 
vessels. 


OPERATIONS  ON  THE   NECK. 


713 


The  Inferior  Thyroid. — Pull  forcibly  the  tumor  to  the  opposite  side, 
retracting  the  muscles  away  from  the  growth  at  the  same  time,  thereby  ex- 
posing the  artery  to  touch  as  it  emerges  obliquely  (Fig.  885)  or  transversely 
from  behind  the  caro- 
tid,   passing    inward 
and  entering  the  thy- 
roid at  the  point  of 
its  attachment  to  tlie 
trachea ;  ligature .  the 
vessels      with      care, 
avoiding    the    recur- 
rent laryngeal  nerve 
ascending  behind  it; 
divide  the  vessels  be- 
tween the  two   liga- 
tures    and     examine 
the  lower  pole  of  the        Fig.  885.— The  ligaturing  of  the  inferior  thyroid  vessels, 
tumor  at   its  median  ^'  "^^^  common  carotid  artery,     h.  The  sterno-mastoid  muscle. 

„  „         ..  c.  The  recurrent  laryngeal  veins,     d.  The   inferior  thv- 

suriace    tor    the    ar-         j-oid  vein. 

teria    thyroidea    ima 

and  the  attending  veins.  Push  back  the  outer  capsule  of  the  goitre  (Fig. 
886) ;  locate  and  isolate  with  the  fingers  at  the  anterior  and  inner  aspects 
of  the  lobe  the  vessels  just  named  and  divide  them  between  two  ligatures. 
Locate^,  isolate,  and  divide  the  isthmus,  and  the  processus  pyramidalis  when 
present.     Free  the  latter,  ligature  and  divide  its  vessels  as  in  the  preceding 

technic;  isolate  the  former  by  first  separat- 
ing and  dividing  the  communicating  veins 
at  the  upper  and  lower  borders  of  the 
isthmus  (in  front  when  present)  between 
two  ligatures;  separate  the  isthmus  from 
the  trachea,  apply  special  forceps  to  it 
firmly,  leaving  uncrushed  only  the  included 
vessels  and  the  connective  tissue,  which  are 
then  firmly  and  securely  ligatured.  Eaise 
upward  the  goitre,  exposing  its  attachment 
to  the  trachea  and  cricoid  cartilage;  catch 
and  tie  all  bleeding  points  and  those  that 
attend  the  severing,  and  leaving  behind  (if 
healthy)  of  the  portion  of  gland  (attached, 
as  above  stated)  for  the  protection  of  the 
recurrent  laryngeal  nerve. 
The  wound  is  then  washed  out  with  a  warm  sterilized  salt  solution, 
surrounding  parts  and  the  hands  purified,  ligature  sutures  tied  after 
putting  on  clean  sterilized  cotton  gloves.  Divided  muscles  are  prop- 
erly sutured,  wound  closed  with  continuous  section,  and  a  small  drain- 
age tube  inserted  and  usually  permitted  to  remain  for  twenty-four  hours 
(Kocher). 


^ 


Fig.  886. — The   ligaturing  of  the 
arteria  thyroidea  ima  vessels. 


lU 


OPERATIVE  SURGERY. 


The  Remarlcs. — The  divided  veins  should  be  retracted  with  the  super- 
ficial tissues  to  avoid  dividing  them  a  second  time. 

The  Angular  Incision. — Kocher  uses  much  less  than  formerly  the  angu- 
lar incision,  reserving  it  for  goitres  that  extend  far  upward  and  are  immov- 


PiG.  887. — The  operation  of  excision  of  goitre  of  left  side  by  angular  incision,  Kocher's 
method,  a.  Anterior  jugular  vein.  •  h.  Sterno-hyoid  muscle,  c.  Communicating 
branch  between  anterior  and  external  jugular  veins,     d.  Inferior  thyroid  veins. 


able,  as  is  frequently  the  case  "  in  very  large  diffused  colloid  tumors  and 
in  inflamed  and  malignant  goitres."  Commence  the  angular  incision  at 
the  level  of  the  thyroid  cartilage  over  the  prominence  of  the  sterno-mas- 
toid  muscle,  and  extend  it  transversely  in  the  direction  of  the  skin  crease 
to  the  median  line  of  the  neck,  thence  vertically  downward  even  to  the 
suprasternal  notch,  if  the  size  of  the  tumor  demands  (Fig.  887),  cutting- 
through  the  skin,  fascia,  and  platysma,  dividing  the  vessels  between  two 
ligatures  as  they  appear,  expose  the  fibers  of  the  sterno-mastoid  at  the 
outer  part  of  the  incision ;  free  the  border  of  the  muscle  and  draw  it  aside 
with  hooks ;  incise  and  draw  upward  the  fascia  that  covers  the  sterno-hyoid 
and  sterno-thyroid  muscles  at  the  middle  portion  of  the  horizontal  incision ; 
divide  in  the  median  line  the  fascia  that  connects  the  sterno-laryngeal  mus- 
cles of  the  respective  sides,  ligaturing  the  vein  that  lies  transversely  above 
the  suprasternal  notch;  free  the  inner  edges  of  these  muscles,  introduce 
the  finger  under  and  partially  divide  them  at  the  upper  ends;  ligature 
divided  vessels  and  draw  aside  with  hooks  the  borders  of  these  muscles^  thus 


OPERATIONS  ON  THE  NECK. 


715 


exposing  the  outer  capsule  of  the  goitre.  The  remaining  steps  of  the  opera- 
tion are  the  same  as  those  of  the  transverse  incision,  to  which  the  reader  is 
referred. 

The  Precautions. — The  patient's  neck  shoukl  be  flexed  from  time  to 
time,  in  order  that  small  veins  emptied  by  extension  may  fill  again  and 
escape  untimely  division.  If  the  proper  capsule  of  the  growth  be  not 
entered  at  first,  the  aimless  efforts  to  isolate  it  will  cause  great  einl)arrass- 
ment  and  lead  to  harmful  delay.  The  application  of  the  ligature  to  the 
thyroid  vessels  at  a  distance  from  the  growth,  or  the  use  of  temporary  liga- 
tures, should  be  practiced  when  proper  isolation  of  the  recurrent  laryngeal 
nerve  is  not  assured.  During  the  separation  of  the  goitre  from  the  trachea 
the  recurrent  laryngeal  nerve  may  be  injured  "  in  spite  of  every  care/'  espe- 
cially where  it  passes  beneath  the  lower  border  of  the  larynx.  To  prevent 
this  accident  Kocher  advises  that  a  posterior  portion  of  the  capsule  of  the 
growth  be  cut  away  and  left  behind  at  that  sitiiation.    In  instances  of  encap- 


FiG.  888. — The  operation  of  excision  of  goitre  of  right  side  through  transverse  incision 
(Fig.  886),  Kocher's  method,  a.  Superior  thyroid  artery  and  vein.  b.  Posterior  bor- 
der" of  thyroid  cartilage,  c.  Sterno-hyoid  and  sterno-thyroid  muscles,  d.  Sterno- 
cleido-mastoid  muscle,  e.  Inferior  thyroid  artery.  /.  Right  common  carotid  artery. 
g.  Right  recurrent  laryngeal  nerve,  h.  Oesophagus.  *  i.  Trachea,  j.  Inferior  thyroid 
vein.     k.  Right  half  of  goitre  turned  out  toward  the  left  side. 


sulated  thyroid  nodules,  not  separable  posteriorly  from  the  internal  thyroid 
capsule,  the  capsule  must  be  cut  through,  but  not  sufficiently  near  to  the 
trachea  to  beget  a  dangerous  removal.  The  possible  adhesion  of  large 
growths  to  the  jugular  vein  should  not  be  overlooked.     Undue  compression 


716 


OPERATIVE  SURGERY. 


upon  or  a  kinking  of  the  pressure-softened  trachea  by  rough  handling  may 
cause  alarming  and  perhaps  fatal  dyspnoea.  Since  the  haemorrhage  and 
the  peculiar  fever  that  often  follow  operation  are  increased  in  direct  propor- 
tion to  the  amount  of  laceration  of  the  thyroid  body  attending  the  removal. 


Fig.  889. — The  operation  of  excision  of  left-sided  goitre,  angular  incision,  Kocher's 
method,  a.  Superior  thyroid  vein.  b.  Superior  thyroid  vessels,  c.  Sterno-mastoid 
muscle,  d.  Sterno-hyoid  muscle,  e.  Inferior  thyroid  artery.  /.  Inferior  thyroid 
vessels,  g.  Goitre  dislocated  to  the  right  over  trachea.  The  inferior  and  superior 
thyroid  arteries  and  veins  are  ligatured. 


needless  injury  of  the  structure  should  be  carefully  avoided.  Alarming 
symptoms  or  sudden  death  may  attend  rough  handling  or  squeezing  of  a 
goitre.    Vertical  incision  for  removal  of  goitre  should  rarely  be  made. 

The  Comments. — A  pair  of  blunt-pointed  scissors  curved  on  the  flat 
are  efficient  instruments  for  enucleation  purposes.  A  bronchocele  may  not 
only  surround  the  trachea,  but  so  insinuate  itself  with  other  important 
structures  as  to  make  the  removal  impossible,  or  the  attempt  unjustifiable. 
Kocher  advises  the  employment  of  local  anaesthesia  in  all  cases  attended 
with  marked  dyspnoea.  General  anaesthesia  causes  engorgement  of  the  ves- 
sels, increases  the  haemorrhage,  and  incites  secondary  bleeding  by  conse- 
quent vomiting.  Kocher  advises  the  use  of  a  one-per-cent  solution  of  cocain 
in  all  suitable  cases,  and  regards  the  dangers  as  being  greatly  lessened  by 
local  anesthesia.  But  little  pain  is  caused,  and  the  consciousness  of  the 
patient  will  permit  of  his  co-operation,  and  of  the  recognition  of  involve- 
ment of  the  recurrent  laryngeal  nerve  by  noting  the  character  of  the  voice. 


OPERATIONS  ON  THE   NECK. 


YIY 


Blind  and  Imrricd  clamping  of  bleeding  pointvS  should  not  be  practiced  in 
this  operatini). 

The  Removal  of  Intra-Thoracic  Goitre. — This  form  of  goitre  may  be 
entirely  overlooked.  For  apparent  reasons  a  goitre  at  this  situation  is  replete 
with  disastrous  probabilities.  Therefore  they  should  receive  early  opera- 
tive attention.  Their  removal  is  especially  difficult,  and  established  plans 
of  procedure  can  hardly  be  formulated.  The  incision  should  be  made  low 
down,  the  angular  being  usually  the  better  one. 

The  upper  pole  of  the  growth  should  be  thoroughly  freed,  the  vessels 
being  secured  by  two  ligatures  each  and  divided,  and  the  isthmus  severed  if 
praetical)le.  The  vessels  related  to  the  surface  of  the  growth  should  be 
ligatured  and  divided,  and  the  sternal  head  of  the  sterno-mastoid,  and  the 
sterno-laryngeal  muscles  of  the  affected  side  should  be  cut  across.  When 
the  tumor  is  raised  upward  all  vessels  as  they  appear  that  are  connected 
with  it  should  be  at  once  tied  and  cut  to  prevent  dangerous  haemorrhage. 
In  the  instances  of  enormous  goitre  that  cannot  be  delivered  through  the 
sterno-cervical  aperture  without  incision  or  tapping — as  in  the  cystic  form, 
and  opening  and  breaking  up  as  in  the  colloid  variety — additional  dangers 
are  encountered,  principally  at  first  from  severe  hemorrhage.  It  is  appar- 
ent in  such  cases  that  delivery  must  be  rapid  and  the  bleeding  promptly 
arrested  to  avoid  the  loss  of  a  patient.  The  inferior  thyroid  vessels  should 
be  controlled  as  soon  as  exposed  by  advancing  delivery.  If  rupture  happen, 
prompt  control  by  digital  pressure  is  the  best,  until  the  vessel  can  be 
clamped.  Careful  after-thought  to  obviate  sepsis  should  be  given.  Strong- 
pronged  forceps  and  suitably  shaped  spoons  for  the 
purposes  of  blunt  dissection  and  lifting  are  requisite. 

Enucleation — Resection  (Kocher).  —  Enucleation- 
resection  is  advised  by  Kocher  as  being  superior  to  enu- 
cleation, because  of  the  severe  haemorrhage  that  often 
attends  enucleation,  and  the  resulting  need  of  pack- 
ing the  wound;  also  the  consequent  danger  of  sep- 
sis, the  delay  in  healing  that  follows  packing,  and  the 
less  certainty  of  permanent  cure  in  cases  of  multiple 
growth  and  those  of  questionable  nature,  than  when 
excision  is  practiced.  Wblfler  concurs  in  these  reasons. 
Expose  the  goitre  through  the  transverse  or  angu- 
lar incision,  as  seems  best;  dislodge  the  growth  as 
before  described  (page  712),  omitting  ligature  of  the 
vessels;  ligature  and  divide  the  isthmus  as  in  the 
preceding  instance  (page  713)  ;  expose  the  inner  bor- 
der of  the  nodule  to  be  enucleated  through  the  cut 
following  division  of  the  isthmus;  separate  the  nod- 
ule from  the  surrounding  gland  tissue  with  a  blunt 
dissector,  so  as  to  allow  the  introduction  of  the  pressure 
forceps,  and  their  use  in  an  upward  and  downward 
direction,  followed  by  the  application  of  a  ligature  to  the  compressed  tissue 
by  means  of  an  aneurism  needle;  divide  the  overlying  gland  tissue  along 


Fig.  890.  —  Kocher's 
grooved  director 
for  operations  on 
goitre. 


718  OPERATIVE  SURGERY. 

the  line  indicated  by  the  needles  (Fig.  891)  between  two  ligatures;  separate 
the  nodnle  at  the  upper  and  lower  parts  from  the  inner  capsule  with  the 
finger;  free  a  fair  extent  of  the  posterior  surface  in  the  same  manner;  divide 
the  posterior  part  of  the  inner  capsule  vertically  at  the  posterior  surface 
with  scissors,  so  that  the  cut  opens  into  the  line  of  section  made  just  before 
at  the  anterior  surface  (Fig.  891,  k) ;  remove  the  nodule  and  the  part  of 
the  gland  lying  in  front  of  it,  and  close  the  wound. 

The  Comments. — Less  bleeding  follows  this  plan  than  in  enucleation 
and  resection,  and  the  piece  of  gland  tissue  remaining  posteriorly  main- 
tains the  needed  function.    The  recurrent  nerve  is  not  exposed  to  injury. 

The  Precautions. — In  cutting  away  the  thyroid  structure,  do  not 
approach  sufficiently  near  to  the  trachea  to  invite  danger  to  it  or  to  the 
laryngeal  nerve. 

Enucleation  (Socin). — Expose  the  surface  of  the  goitre  through  a  median 
incision,  or  one  made  over  the  anterior  border  of  the  sterno-mastoid,  accord- 
ing to  the  prominence  of  the  growth  (Socin).  Separate  the  sterno-laryn- 
geal  muscles  and  draw  their  borders  apart;  draw  aside  the  omo-hyoid  if 
practicable,  if  not,  divide  it;  expose  the  surface  of  the  tumor  by  division 
of  the  overlying  tissue  at  the  situation  of  the  nodule.  It  is  recognized  by 
its  bluish  white  covering,  and  enucleated  through  the  incision  made  down 
upon  it,  deeply  or  superficially,  as  the  case  may  be,  arresting  lijemorrhage  as 
it  occurs. 

Kochers  Incision. — Expose  the  capsule  as  noted  on  page  711  et  seq. ; 
incise  the  gland  tissue  at  prominent  points  until  the  nodules  appear,  arrest- 
ing bleeding  with  f  orcipressure ;  shell  out  the  nodule  with  a  suitable  instru- 
ment by  blunt  dissection,  reducing  the  size  by  incision  if  advisable;  arrest 
bleeding  with  forceps,  the  need  being  greater  the  deeper  the  blunt  dissection. 
If  enucleation  be  not  feasible,  supplement  by  excision  or  enucleation- 
resection. 

The  Comments. — Enucleation  is  suited  to  instances  of  crippling  of  the 
gland  by  previous  operations  on  the  opposite  side,  when  a  limited  number 
(two  or  three)  of  isolated  nodules  are  present  in  otherwise  healthy  gland 
structure,  when  a  single  nodule  causing  extensive  pressure-atrophy  of  the 
gland  substance  is  present,  and  the  latter  is  noted  only  at  the  posterior 
aspect  of  the  tumor,  and  when  as  the  result  of  inflammation  or  hsemor- 
rhage  the  goitre  is  adherent  to  the  external  capsule  (Kocher). 

The  Comments. — The  recurrent  laryngeal  nerve  is  not  exposed  to  dan- 
ger in  this  operation;  the  healthy  structure  of  the  organ  is  preserved,  and 
deformity  is  prevented.  Attempted  cure  by,  injection  complicates  enuclea- 
tion. In  some  instances  hgemorrhage  is  quite  profuse.  Temporary  or  per- 
manent ligature  of  the  arteries  may  be  practiced.  However,  the  indication 
is  commonly  well  met  by  elastic  constriction  around  the  neck  of  the  affected 
part  of  the  gland  (Bose).  This  operation  is  adapted  to  the  cure  of  cysts 
and  solid  tumors  of  established  size,  but  not  to  advancing  goitre,  as  then 
recurrence  is  quite  certain.  A  free  incision  may  not  be  required  for  the 
removal  of  each  independent  cyst,  as  g,  contiguous  cyst  may  be  removed 
through  the  thin-walled  compartment  of  another. 


OPERATIONS   ON  THE   NECK. 


719 


Enucleation  is  regarded  by  many  operators  with  great  favor.  Nearly 
2,700  cases  are  reported  in  which  neither  haemorrhage,  sepsis,  nor  cachexia 
caiised  death.  Operative  involvement  of  the  recurrent  laryngeal  nerves  and 
oi'  other  important  contiguous  structures  are  less  frequent  than  in  the  more 
extended  operations.  Shepard  strongly  favors  the  method  in  both  solid  and 
cystic  tumors.  In  their  removal  he  adheres  closely  to  the  outer  limits  of 
each;  in  the  latter  he  taps  the  sac,  grasps  it  with  forceps,  and  carefully 
removes  it.  In  each  instance  haemorrhage  is  arrested  by  ligatures  and  gauze 
packing,  the  wound  sutured  above  and  left  open  below  for  removal  of  the 
gauze. 

Resection  of  Goitre  (Thyroidectomy)  (Kocher). — Cases  in  which  the 
nodules  are  small  and  prominent  and  apparently  isolated  and  bleeding  sur- 
faces can  be  controlled  after  division  are  suitable  for  this  measure.  Diffuse 
colloid  changes  difficult  to  raise  may  be  treated  by  this  method.    However,  it 


/' 


y 


^J 


Fig.  891. — The  operation  of  enucleation-resection  of  a  hypertrophied  nodule  from  tlje 
left  lobe,  Kocher's  method,  a.  Angle  of  thyroid  cartilage,  b.  Cricoid  cartilage,  c. 
Piece  of  posterior  portion  of  capsule  of  goitre,  d.  Ligatured  isthmus,  e.  Healthy 
portion  of  thyroid.  /.  Trachea,  g.  Inferior  thyroid  vein.  h.  Upper  horn  of  thyroid 
and  superior  thyroid  vessels,  i.  Cut  surface  of  isthmus.  /.  Surface  of  nodule,  k. 
Line  of  division  of  capsule  of  goitre  at  posterior  surface.  (This  line  is  located  too  far 
forward.)  I.  Lower  horn  of  thyroid.  The  left  lobe  is  dislocated  through  the  inci- 
sion, isthmus  ligatured,  cut  across,  and  the  cut  surfaces  drawn  apart  so  as  to  expose 
nodule. 


may  be  better  to  practice  unilateral  excision,  and  should  difficulty  of  healing 
be  apprehended  from  persistence  of  the  morbid  growth  primary  ligation  of 
the  vessels  should  be  practiced.  Eesection  of  the  growth  is  sometimes  done 
for  relief  from  the  severe  pressure  symptoms  incident  to  colloid  degenera- 


720  OPERATIVE  SURGERY. 

tion  of  both  lobes,  or  of  the  malignant  complications,  as  well  as  for  their 
cure.  A  long  transverse  incision  is  made  with  an  upward  extension  at  both 
ends,  followed  by  a  free  transverse  division  of  the  muscles,  when  necessary, 
with  ligature  of  the  main  vessels  of  one  side  and  a  vessel  above  or  below 
on  the  other  side.  When  practicable  forward,  successive  luxation  of  the 
respective  halves  of  the  growth  is  done,  and  resection  practiced  under  elas- 
tic tension,  supplemented  with  numerous  artery  forceps.  Angiotribes  and 
other  forms  of  tissue  crushers  can  be  well  employed  in  these  cases.  In  this 
way  only  can  partial  removal  of  both  lobes  be  practiced  without  extensive 
haemorrhage  when  cutting  through  the  thyroid  tissue.  The  overlying  struc- 
tures involved  in  malignant  growths  should  also  be  dissected  away. 

The  Bemarlcs. — At  the  best,  resection  of  a  goitre  is  a  difficult  and  often 
a  dangerous  measure.  In  this  class  of  cases  difficulty  of  breathing  is  fre- 
quently present.  And  in  these,  as  in  others  similarly  afflicted,  ether  is 
contraindicated.  Slight  morphin  narcosis  and  cocain  anaesthesia  should  be 
employed  instead.  In  so-called  complete  extirpation  a  small  portion  of 
gland  is  left,  and  often  a  pyramidal  process  (third  lobe)  remains.  Ligature 
and  division  of  the  isthmus  has  been  advised  for  the  relief  of  pressure 
dyspnoea  in  inoperable  cases.  Wolfler  practiced  "  operative  dislocation " 
for  the  same  purpose,  the  goitre  being  raised  from  its  bed  without  cutting 
the  arteries,  and  transplanted  to  a  more  favorable  situation.  In  malignant 
disease  the  fatal  outcome  is  so  pronounced  as  to  almost  forbid  the  practice. 
Thirty-three  per  cent  die  from  the  operation,  and  60  per  cent  die  within 
six  and  84  per  cent  within  eight  months  after  operation. 

Recurrent  Goitre. — Eecurrent  goitre  happens  in  about  18  per  cent  of 
the  cases,  the  majority  of  which  follow  enucleation.  Kocher  advises  the 
following  general  plan  of  operative  treatment :  Expose,  free,  and  isolate  the 
tumor  in  the  usual  manner.  If  the  upper  pole  is  healthy,  crush  the  gland 
the  width  of  the  forceps  so  as  to  leave  the  healthy  part  still  supplied  with  its 
vessels;  ligature,  divide,  and  remove  through  the  part  crushed  the  diseased 
portion ;  repeat  the  act  with  the  remainder  of  the  gland.  If  the  upper  pole  he 
entirely  diseased  and  dislocation  cannot  be  done  without  ligature,  then  first 
tie  the  superior  thyroid  vessels,  dislocate  the  tumors,  ligature  the  vessels  at 
the  lower  pole,  raise  the  tumor  with  the  trachea,  leaving  gland  tissues  at- 
tached if  practicable.  Control  deep  vessels  near  the  trachea,  incise  goitre  tis- 
sue vertically  near  the  isthmus,  thus  forming  a  posterior  capsule  from  which 
the  diseased  material  is  scraped.  By  continued  dissection  a  flat  mass  of  goitre 
tissue  is  separated  posteriorly  sufficient  to  maintain  the  thyroid  functions. 

The  scars  of  previous  operations  complicate  the  removal,  which  is 
patiently  conducted  with  the  idea  of  removing  the  diseased  and  leaving 
behind  enough  well-nourished  normal  tissue  to  meet  the  functions  of  the 
gland. 

The  Treatment  by  Ligature  of  the  Thyroid  Arteries.— The  ligature  of  the 
superior  thyroid  is  not  difficult  or  especially  dangerous  (page  197).  Liga- 
ture of  the  inferior  thyroid  is  more  difficult,  and  incurs  special  dangers  from 
the  involvement  of  important  structures  (page  177).  Kocher  reaches  the 
vessel  through  an  incision  made  along  the  inner  border  of  the  sterno-mastoid, 


OPERATIONS  ON  THE  NECK.  Y21 

and  ties  the  artery  in  front  of  the  scalenus  anticns.  Rydygier  made  a 
transverse  incision  three  inches  in  length,  one  inch  aljove  the  clavicle, 
so  that  more  than  half  the  length  lies  behind  the  sterno-mastoid  mus- 
cle, through  which  he  exposes  the  thyroid  axis,  and  secures  and  ligatures 
the  artery. 

The  Comments. — The  rapidly  developing  parenchymatous,  vascular 
goitres,  especially  in  the  young  and  those  unfitted  for  enucleation,  are  proper 
cases  for  treatment  by  ligature.  The  gradual  atrophy  following  simultane- 
ous ligature  of  both  of  the  arteries  does  not  appear  to  expose  the  patient  to 
the  common  sequels  of  complete  removal  of  the  thyroid  body.  The  vascular 
goitre  of  Graves's  disease  is  suited  to  this  procedure.  Trendelenburg  ties 
the  arteries  of  one  side,  a  month  later  those  of  the  other.  Wolfler  and  Porta 
have  practiced  the  same  with  favorable  results.  Kocher  advises  that  the 
artery  supplying  the  portion  of  the  thyroid  involved  should  be  tied  first,  and 
be  followed  by  ligature  in  order  of  the  vessels  supplying  succeeding  enlarge- 
ments, provided  that  a  beneficial  effect  be  noted.  The  different  plans  of 
action  advised,  and  the  uncertainty  of  the  outcome  from  the  ligature,  to- 
gether with  the  difficulty  attending  it  in  many  instances  when  compared 
with  the  established  technique  and  success  of  the  radical  methods,  leave  but 
a  limited  field  of  utility  in  this  disease  for  ligature. 

Exothyropexy  (Jaboulay). — Exothyropexy  consists  in  freeing  the  gland 
from  its  capsular  environment,  raising  and  fixing  it  superficially  in  the 
wound,  and  leaving  it  to  granulate  and  adhere  under  antiseptic  dressing. 
The  influence  of  exposure  to  air,  and  of  resulting  venous  sinus  thrombosis, 
contribute  to  the  shrinkage.  Poncet,  Wol'ller,  and  others  have  secured  in 
this  manner  a  limited  shrinkage  of  the  gland.  The  presence  of  thrombosis 
and  the  laceration  attendant  on  the  displacement  are  elements  of  danger 
from  systemic  infection.  In  cases  of  threatened  suffocation  high  or  low 
tracheotom}-,  according  to  the  size  and  situation  of  the  goitre,  with  the  in- 
troduction of  a  tube  suited  to  the  peculiar  requirements  of  the  case  (Fig. 
867,  0  and  m),  is  a  wise  preliminary  step  and  often  a  proper  final  measure. 
It  seems  especially  fitted  for  the  relief  of  dyspnoea  of  parenchymatous  and 
other  inoperable  goitres.  Larger  experience  is  required  to  establish  the 
practicalulity  of  the  measure  in  all  respects. 

Excision  of  the  Sympathetic. — Jahoiday  and  Jonnesco  have  advised  and 
practiced  this  measure  for  the  relief  of  patients  with  exophthalmic  goitre 
(see  Vol.  II,  page  1518). 

The  injection  of  goitre  for  cure  is  now  practiced  much  less  than  formerly. 
Injection  should  not  be  employed  at  all  in  cases  for  which  operation  is 
contemplated,  on  account  of  the  periglandular  adhesions  that  it  causes, 
which  beget  special  difficulties  in  the  event  of  subsequent  operation.  The 
cystic  and  recent  follicular  varieties  are  those  to  which  the  treatment  is 
best  suited.  The  excellent  results  now  obtained  by  operation  limit  the 
use  of  injections  to  the  narrow  and  illogical  field  of  unsurgical  expediency. 
The  tincture  of  iodine  (five  to  ten  drops)  and  a  like  amount  of  carbolic- 
acid  solution  (five  per  cent)  are  regarded  as  the  best  medicinal  agents 
for  the  purpose.     Strict  aseptic  precautions  throughout  should  be  taken. 


722  OPERATIVE  SURGERY. 

The  needle  should  be  thrust  slowly  into  the  gland,  carefully  avoiding  the 
superficial  veins;  the  syringe  is  then  removed  to  see  if  blood  will  escape 
through  the  needle,  thus  avoiding  the  introduction  of  the  fluid  into  a  vein. 
Eight  or  ten  drops  of  the  fluid  are  then  slowly  injected,  watching  carefully 
the  effects  of  the  introduction.  But  one  injection  is  made  at  a  sitting, 
and  an  interval  of  three  or  four  days  should  have  elapsed  before  it  is  re- 
peated. Different  aspects  of  the  tumor  are  subjected  to  treatment.  Senn 
speaks  in  high  terms  of  the  carbolic-acid  treatment  established  by  Gunn. 
Schwartz  regards  iodine  as  the  most  efficacious  and  least  dangerous  for  ordi- 
nary cystic  goitre.  Heymann  reports  16  deaths  from  injection,  one  of  which 
happened  suddenly  after  the  use  of  iodine,  which  had  been  injected  twice 
per  week  for  four  months. 

The  Dangers  of  tlie  Operations. — Hfemorrhage  is  a  constant  danger 
during,  and  it  may  happen  after,  the  operation.  If  care  be  exercised  to 
divide  nothing  incautiously  and  to  divide  the  vessels  between  two  liga- 
tures, but  little  annoyance  is  likely  to  happen  from  this  cause  during 
operation,  unless  the  growth  be  a  soft  and  highly  vascular  one,  when  a 
startling  and  profuse  bleeding  will  be  provoked  by  opening  the  capsule. 
The  difficulty  of  finding  and  securing  the  bleeding  points  in  such  cases  is 
often  trying,  and  may  seriously  test  the  composure  of  the  surgeon.  If  care- 
ful scrutiny  be  exercised  to  detect  bleeding  points  before  the  wound  is 
closed,  and  the  ligatures  have  been  securely  placed  during  operation,  no 
rational  fear  need  be  felt  regarding  hsemorrhage  thereafter.  The  danger 
of  the  entrance  of  air  into  the  veins  is  especially  prominent  here  because 
of  their  great  number,  large  size,  and  intimate  relation  with  the  influence 
of  respiratory  aspiration.  These  peculiarities  contribute  to  danger  from 
the  use  of  injections,  and  to  the  presence  of  thrombi.  Gentle  manipula- 
tions of  the  tumor  are  essential  to  security  of  the  patient. 

The  Recurrent  Laryngeal  Nerve. — If  this  nerve  be  cut,  bruised,  or  in- 
cluded in  a  ligature  during  operation,  serious  laryngeal  manifestations  may 
occur  at  the  time  or  may  happen  afterward.  Undue  dragging  on  the  nerve, 
its  involvement  in  cicatricial  formation,  or  the  presence  of  neuritis  may 
cause,  aphonia  after  operation.  Fortunately,  however,  these  manifestations 
are  not  always  permanent.  Large,  adherent,  illy-defined  tumors  are  dan- 
gerous for  this  reason,  as  are  those  surrounding  closely  the  trachea  and 
oesophagus.  A  subsequent  operation  may  be  necessary  to  relieve  these  symp- 
toms. The  lymphatic  duct,  especially  the  right,  may  be  bruised  or  torn 
during  the  removal  of  large  or  low  goitres.  The  distinctive  appearance  of 
the  lymph  will  suggest  the  nature  of  the  structure  involved. 

Cellulitis. — Cellulitis  of  a  septic  nature  may  follow  operation  even  for 
small  growths,  and  lead  to  the  formation  of  pus  in  the  mediastinum.  A 
scrupulous  aseptic  technique  will  obviate  this  danger. 

Cachexia  Thyreopriva. — Cachexia  thyreopriva  manifests  its  presence  by 
a  species  of  tetany  and  myxoedema.  The  continued  and  frequent  occurrence 
of  these  sequels  in  complete  extirpation  led  to  its  abandonment  except 
in  malignant  disease.  The  removal  of  a  greater  or  lesser  fractional  part 
of  the  gland  may  be  followed  by  these  manifestations  in  a  minor  degree. 


OPERATIONS  ON  THE  NECK.  Y23 

However,  the  best  evidence  of  their  infrequency  is  witnessed  by  the  fact 
that  in  1,600  cases  of  operation  by  Kocher's  method  but  4  suffered  from 
this  sequel. 

The  dressing  of  the  luoiind  requires  no  especial  technique.  The  cavity  of 
the  wound  is  mopped  with  an  aseptic  solution  or  wiped  dry ;  loose  clots  are 
removed,  and  all  bleeding  points  are  arrested.  The  margins  of  the  wound 
are  carefully  united  with  silkworm-gut  sutures,  and  drainage  is  employed  at 
the  dependent  parts.  The  walls  of  the  wound  are  pressed  together  and 
dead  spaces  eliminated  by  catgut  sutures,  and  sponge  pressure  carefully 
adjusted  and  equalized  by  a  thick  covering  of  absorbent  cotton  held  in  place 
with  bandages.  If  the  bandages  are  applied  too  tightly  much  discomfort 
will  follow.  A  mild  pharyngitis,  attended  with  profuse  expectoration  of 
mucus,  often  occurs,  as  in  other  operations  on  the  neck,  at  the  sides,  and  at 
the  median  line. 

The  after-treatment  is  of  a  routine  character.  The  head  is  kept  flexed 
as  much  as  comfort  will  permit,  and'  the  dressings  are  changed  to  conform 
with  needed  cleanliness.  The  drainage  isrem.oved  after  a  day  or  two.  The 
food  should  be  bland  and  nutrient,  and  fresh  air  freely  provided. 

The  Results. — The  -iO-per-cent  death  rate  of  forty-five  years  ago  was 
reduced  to  21  before  1871,  and  to  11  per  cent  before  1877.  In  1895 
Kocher  reported  1,000  cases  of  benign  goitre  operated  on  by  himself,  with 
an  operation  death  rate  of  1  per  cent.  To  this  list  can  now  be  added  700 
others,  of  which  Kocher  performed  550  and  his  assistants  the  remainder. 
The  last  600  of  this  series  includes  18  malignant  and  15  exophthalmic 
cases,  and  still  the  average  death  rate  is  but  1  per  cent.  Kocher  stjll  later 
reports  1,100  operations  with  three  deaths.  Kronlein  and  Sulzer  report 
200  and  144  cases  respectively  without  a  death.  A  2-per-cent  rate  of  mor- 
tality is  now  a  fair  estimate  of  the  results  of  experienced  hands  in  benign 
cases.  The  outlook  in  malignant  cases  is  gloomy.  Kocher's  operative 
death  rate  is  33.33  per  cent.  The  average  duration  of  life  is  about  six 
months  (Orcel)  ;  84  per  cent  die  in  six  and  60  per  cent  in  eight  weeks 
(Rotter).  In  exophthalmic  goitre  the  rate  of  mortality  from  operation 
is  well  shown  by  the  cases  collected  by  Starr.  In  190  cases  74  were 
cured,  45  improved,  3  unimproved,  and  23  died  from  the  operation. 
The  remaining  45  not  stated.  The  mortality  rate  varies  from  7  (Kinni- 
cutt)  to  12  or  15  per  cent,  depending  on  the  judgment  and  operative  skill 
of  the  surgeon. 

Wounds  of  the  Neck. — Incised,  stab,  and  gunshot  wounds  of  the  neck  are 
of  not  infrequent  occurrence.  Incised  wounds  happen  oftenest  because  of 
suicidal  attempts.  The  location  and  extent  of  the  incision  modify  its  severity. 
If  at  the  front  and  above  the  hyoid  bone,  the  base  of  the  tongue  may  be  in- 
volved, if  through  the  thyro-hyoid  space,  the  epiglottis  and  pharynx  (Fig. 
870),  if  lower,  the  larynx  and  trachea  respectively  may  be  involved.  In  at- 
tempted suicide  the  wounds  at  the  median  line  are  often  shallow,  the  force  of 
the  attempt  being  outwardly  expended  on  the  lower  jaw.  Incision  through 
the  thyro-hyoid  space  occurs  most  frequently.  If  the  wound  be  superficial, 
but  little  harm  may  arise;  if  deep,  free  division  of  the  air  passage  and  per- 
47 


724  OPERATIVE  SURGERY. 

haps  of  important  vessels  on  either  side  is  followed  more  or  less  promptly  by 
death  from  haemorrhage  or  asphyxia,  unless  relieved.  Deep  wounds,  involv- 
ing the  spaces  immediately  above  and  below  the  hyoid  bone,-  incite  suffoca- 
tion from  the  closure  of  the  larynx  by  the  down-falling  of  the  base  of  the 
divided  tongue  and  of  the  divided  epiglottis  respectively.  Inflowing  blood 
is  an  important  element  of  immediate  and  remote  danger  in  all  instances  of 
air-passage  involvement,  causing  infection  in  the  first  and  septic  inflamma- 
tion of  the  lungs  and  bronchi  in  the  latter  instance.  CEdema  of  the  glottis 
and  emphysema  of  the  connective  tissue  are  common  and  important  com- 
plications of  these  wounds,  the  former  happening  most  frequently  with  upper 
and  the  latter  with  lower  involvements  of  the  air  passages.  The  importance 
of  gunshot  and  stab  wounds  relates  to  the  direction  and  extent  of  injury. 
The  important  vessels  and  nerves,  the  oesophagus,  the  trachea,  and  even  the 
pleural  cavity  and  lung  itself,  may  be  involved  in  these  injuries. 

Fracture  of  the  larynx  and  hyoid  bone  may  result  from  direct  blows  and 
from  manual  choking.  These  injuries  may  so  deform  and  cripple  the  parts 
as  to  threaten  suffocation  in  the  former,  and  cause  much  pain  and  annoy- 
ance in  the  latter  instance. 

The  Treatment. — The  treatment  is  regulated  by  the  urgency  of  the  symp- 
toms. Severe  haemorrhage  and  asphyxia  demand  instant  arrest  of  bleeding, 
the  removal  of  obstruction,  and  the  performance  of  tracheotomy,  if  then 
required.  When  time  will  permit,  thorough  asepsis  should  be  practiced. 
In  wounds  involving  the  air  passages  the  arrest  of  bleeding  is  of  double  sig- 
nificance, preventing  the  entrance  of  blood  into  the  respiratory  passages  as 
well  as  the  loss  to  the  patient.  Temporary  tracheotomy  is  usually  required 
in  wounds  of  the  trachea,  the  larynx,  and  the  pharynx,  especially  the  latter 
two,  in  order  that  the  danger  incurred  by  the  sudden  advent  of  oedema  of 
the  glottis  may  be  forestalled.  Wounds  of  the  trachea  may  be  closed  with 
catgut  at  once  and  tracheotomy  omitted.  In  wounds  of  other  kinds  the  tube 
may  be  inserted  at  the  seat  of  injury  or  through  a  high  tracheotomy,  if  the 
location  of  the  wound  permits.  In  wounds  involving  the  pharynx,  trache- 
otomy is  often  advisable  as  the  best  means  of  avoiding  the  septic  exposures 
arising  from  discharges  provoked  by  food  contact,  as  well  as  the  dangers  of 
cedema  of  the  glottis.  Tracheotomy  permits  of  careful  cleansing  and  closure 
of  the  original  wound  in  many  instances.  In  wounds  of  the  oesophagus, 
infiltration  of  the  deep  tissues  of  the  neck  from  swallowing  food  and  fluid 
may  happen  before  the  existence  of  an  injury  is  suspected.  In  stab  and 
gunshot  wounds  of  the  trachea  extensive  and  dangerous  emphysema  may 
arise,  requiring  tracheotomy  and  free  incision  for  relief.  A  gunshot  wound 
of  the  neck,  passing  contiguous  to  but  not  involving  the  trachea,  and  enter- 
ing the  lung,  may  cause  extensive  emphysema  and  otherwise  simulate  in 
all  important  respects  a  wound  of  the  trachea.  (Esophageal  wounds  should 
be  exposed  at  once,  cleansed,  and,  if  clean  cut,  sutured.  Eagged  wounds, 
howsoever  inflicted,  should  be  treated  by  drainage  and  packing.  In  no 
instance  is  it  wise  to  completely  close  a  wound  in  case  of  oesophageal  involve- 
ment (page  596),  because  the  uncertainty  of  union  of  the  tube  renders  pri- 
mary closure  unsafe.     Wounds  of  the  tongue  and  epiglottis  are  sewed  care- 


OPERATIONS  ON   THE  NECK. 


T25 


fully  at  once,  the  divided  borders  of  the  mucous  membrane  of  the  pharynx 
being  closely  apposed  by  sewing  before  the  more  superficial  structures  are 
united.     In  all  suitable  instances  wounds  of  the  neck  should  be  carefully 

closed.  The  divided  borders  of 
the  muscles  and  gaping  structures 
should  be  united  with  sutures  to 
secure  prompt  and  effective  union, 
thus  eliminating,  dead  spaces.  Af- 
ter suture  of  the  soft  parts  the  neck 
is  flexed,  and  sufficient  pressure  is 
applied  to  cause  still  further  the 
approximation  and  retention  essen- 
tial to  the  prevention  of  dead 
spaces  and  to  good  union.  Drain- 
age should  be  employed  only  in 
the  instance  of  suspected  infection. 
Fixed  position  of  the  neck,  clean- 
liness, alimentation  by  the  bowel 
for  a  day  or  so  in  case  of  pharyn- 
geal wound,  followed  by  feeding 
by  the  stomach  tube,  are  impor- 
tant measures  of  treatment.  If  the 
head  be  lowered  for  the  first  two 
or  three  days,  an  increase  of  blood 
in  the  brain  and  the  flow  of  the 
discharges  away  from  the  wound 
will  be  favored.  The  tracheal, 
the  oesophageal,  and  laryngeal  se- 
quels should  be  treated  as  necessity 
demands. 

Abscess  and  Phlegmon  of  the 
Neck. — ^Abscess  and  phlegmon  of 
the  neck  located  in  the  sublingual 
(Lud wig's  angina),  submaxillary, 
and  parotid  regions,  also  at  the  an- 
terior and  lateral  cervical  regions 
from  glandular  involvement,  not 
infrequently  occur.  In  each  in- 
stance early  relief  should  be  sought 
by  free  incision. 

The  awaiting  the  presence  of 
fluctuation  while  encouraging  its 
appearance   by   poultices,   etc.,   is 


Fig.  893.  —  Arrangement  of  the  deep  cervical 
fascia,  muscles,  vessels,  nerves,  etc.,  as  shown 
by  transverse  section  on  level  with  sixth  cer- 
vical vertebra,  a.  Anterior  jugular  vein.  h. 
Sterno-hyoid  muscle,  c.  Omo-hyoid  muscle. 
d.  External  jugular  vein.  e.  Internal  jugu- 
lar vein.  /.  Common  carotid  artery,  g. 
Pneumogastric  nerve,  li.  Vertebral  vessels. 
i.  Sympathetic  nerve.  /.  Descendens  hypo- 
glossi  nerve,     k.  Recurrent  laryngeal  nerve. 


often  fraught  with  grave  dangers 
from  purulent  and  serous  infection,  infiltration  of  the  deep  tissues  of  the 
neck,  and  oedema  glottidis,  especially  in  those  cases  located  below  the  infe- 
rior maxilla.      Extensive  sloughing  of  the  connective  tissue  of   the  neck, 


Y26  OPERATIVE  SURGERY. 

attended  with  foetid  gas,  have  been  seen  by  the  writer.  The  relief  of  the 
tension,  prevention  of  sloughing,  and  extensive  infiltration  of  morbid  prod- 
licts,  even  into  the  thorax,  requires  early  and  decided  action.  Also  the 
liability  to  sudden  and  fatal  oedema  of  the  glottis  demands  the  exercise  of 
the  forethought  necessary  to  meet  and  relieve  the  complication  at  once  by 
bronchotomy  (page  681). 

Retropharyngeal  Abscess. — Retropharyngeal  abscess  is  not  an  infrequent 
affection,  especially  in  children.  Phlegmonous  inflammation  of  the  pharyn- 
geal tissues,  the  softening  of  diseased  lymphatic  glands,  and  caries  of  the 
bodies  of  cervical  vertebrse,  are  frequent  causes  of  this  variety  of  abscess. 

The  Anatomical  Points. — The  relations  of  the  various  extensions  of  the 
deep  cervical  fascia  to  the  oesophagus,  pharynx,  and  the  other  deep  struc- 
tures of  the  neck  (Fig.  892),  together  with  the  fact  that  the  lower  limit 
of  the  pharynx  corresponds  to  the  intervertebral  disk  of  the  fifth  and  sixth 
cervical  vertebrae,  and  the  liability  of  the  extension  by  burrowing  of  post- 
pharyngeal suppuration  into  the  thorax,  are  individually  and  collectively 
important  items  (Gerster) .  Retropharyngeal  abscess  may  be  opened  inter- 
nally through  the  pharj^nx  and  externally  through  the  neck  at  two  situations. 

The  evacuation  through  the  mouth  is  not  advisable,  except  in  the  instance 
of  small  collections  of  pus  dependent  upon  transient  causes.  The  chronic 
discharge  of  pus  into  the  pharynx  is  objectionable  from  nearly  every  stand- 
point, and  especially  when  the  disease  is  thus  protracted  by  inefficient  drain- 
age and  inadequate  cleanliness.  If  it  be  determined  to  evacuate  the  abscess 
through  the  pharynx,  cleanse  the  part  thoroughly,  place  the  patient  on  the 
back  in  a  good  light,  cocainize  the  mucous  membrane,  fasten  the  jaws  apart, 
seize  the  tongue  and  draw  it  forward.  The  end  of  the  left  index  finger  is 
placed  against  the  prominent  fluctuating  point, 
and  the  patient  is  caused  to  inspire  deeply.  A 
sharp-pointed  bistoury,  its  blade  protected,  ex- 
cept at  the  point,  with  adhesive  plaster,  is  then 
(Fig.  893)  carried  along  the  finger  into  the 
abscess,  and  an  opening  is  made  downward 
or  upward,  according  to  the  location  of  the 
point  of  greatest  prominence,  half  an  inch  or 
so  in  length  (Fig.  893).  As  the  fluid  escapes, 
the  finger  is  withdrawn,  and  the  patient  turned 
over  and  caused  to  expire  forcibly,  so  as  to 
clear  the  throat  of  the  discharge.  Sponging  ^^^^  893.-Opening  a  retro- 
with  sterilized  water,  to  remove  the  pus  and  pharyngeal  abscess, 

promote  cleanliness,  is  practiced  from  time  to 

time  until  healing  takes  place.  In  every  instance  when  extended  suppura- 
tion is  anticipated,  the  evacuating  incision  should  be  made  from  without, 
behind,  or  in  front  of  the  sterno-mastoid  muscle. 

CMene's  Method. — Chiene  made  an  incision  from  the  mastoid  process 
downward  along  the  posterior  border  of  the  sterno-mastoid  muscle  the 
proper  distance  through  the  integument  and  fascia,  drew  the  posterior  bor- 
der of  the  muscle  forward  and  passed  in  front  of  the  scalenus  anticus. 


OPERATIONS  ON  THE  NECK.  '72Y 

(Fig.  892)  behind  the  deep  vessels  and  the  longus  colli  to  the  retropharyn- 
geal space,  by  means  of  blunt  dissection. 

This  plan  of  evacuation  is  a  comparatively  simple  one,  as  no  important 
structures  intervene.     The  course  is  direct,  the  drainage  quite  dependent, ' 
and  any  resulting  disfigurement  is  at  the  side  rather  than  in  the  front  of 
the  neck.    This  plan  is  to  be  commended. 

Buckhardt's  Method. — Bucl-hardt  made  an  incision  at  the  anterior  bor- 
der of  the  sterno-mastoid  muscle,  at  the  level  of  the  larynx,  through  the  skin 
and  platysma,  and  reached  the  vessels  of  the  thyroid  body,  which  he  pushed 
aside.  The  carotid  sheath  was  quickly  exposed  and  drawn  outward  along 
with  its  contents  by  means  of  a  hook.  The  prevertebral  fascia  covering 
the  longus  colli  (Fig.  892)  was  quickly  opened,  and  the  prevertebral  space 
promptly  gained  by  blunt  dissection  directed  transversely  inward  across  the 
muscle.  The  only  vessels  directly  in  the  course  of  this  dissection  were  a 
small  subcutaneous  vein,  which  was  tied  between  two  ligatures,  and  the 
thyroid  vessels,  which  were  pushed  aside.  The  route  by  the  latter  method 
is  somewhat  shorter,  and  the  field  of  disease  is  more  easily  exposed.  How- 
ever, the  drainage  is  less  free  and  the  disfigurement  more  prominent  than 
in  the  former. 

The  Remarhs. — Tuberculous  products,  foreign  bodies,  and  diseased  bone 
should  be  removed  carefully,  suitable  drainage  introduced,  cleanliness 
secured,  and  repair  encouraged  by  the  recognized  antiseptic  means. 

The  Results. — Little  or  no  danger  arises  from  the  operation  if  conducted 
antiseptically  and  with  care.  The  final  outcome  is  dependent  on  the  nature 
of  the  disease  causing  the  abscess. 

The  Removal  of  Diseased  Cervical  Lymphatic  Glands.— The  devious  and 
unforeseen  relations  that  exist  between  diseased  cervical  glands  and  the 
important  superficial  and  deep  structures  of  the  neck,  invest  their  removal 
with  a  sense  of  responsibility  that  often  begets  a  strong  feeling  of  uncer- 
tainty as  to  the  wisdom  of  the  attempt  in  many  instances.  Apparently 
simple  cases  often  become,  as  the  operation  progresses,  difficult  and  com- 
plex, and  sometimes  even  dangerous  of  execution.  It  is  wise,  therefore,  that 
the  patient  or  the  friends  be  given  at  the  outset  a  quite  definite  idea  of  the 
uncertainties  that  too  often  are  a  serious  part  of  the  procedure.  At  all 
events,  they  ought  not  to  be  permitted  to  regard  the  operation  as  trivial. 
The  glands  may  be  more  or  less  firm  and  independently  encapsulated 
or  broken  down  and  adherent  to  each  other.  Caseous  and  inflammatory 
products  may  take  the  place  of  or  mingle  with  definite  gland  structure. 
The  superficial  and  deep  series  of  glands  may  be  affected  independently 
of  each  other,  but  usually  they  are  diseased  conjointly,  although  in  an 
irregular  and  often  unexpected  manner.  An  easily  removable  diseased 
superficial  series  may  communicate  freely  with  a  deep  one  that  is  intri- 
cately associated  with  important  structures. 

The  Anatomical  Points. — Before  attempting  the  removal  in  pronounced 
cases,  the  course  and  relation  of  the  superficial  and  deep  nerves  and  vessels 
should  be  reviewed.  The  superficial  branches  of  the  cervical  plexus  are 
especially  exposed  to  division.     The  cervico-facial  branch  of  the  facial  nerve 


T28 


OPERATIVE  SURGERY. 


and  its  terminal  branches  may  be  injured,  causing  objectionable  paralysis  of 
the  lower  lip.  The  relation  of  the  spinal  accessory  to  the  upper  end  of  the 
sterno-mastoid  is  of  great  importance.  The  relation  of  the  superficial  and 
deep  glands  with  the  sterno-mastoid  muscle,  and  the  latter  with  the  deep 
glands  of  the  neck,  are  matters  of  great  significance.  Any  good  text-book 
on  anatomy  will  illustrate  forcibly  these  important  features.  The  presence 
and  location  of  the  lymphatic  ducts  should  not  escape  attention. 


Fig.  894. — The  instruments  employed  in  removal  of  diseased  cervical  lymphatic  glands. 

a.  Scalpels,  large  and  small,  h.  Porcipressure,  curved  and  straight,  c.  Forceps,  dis- 
secting and  mouse-tooth,  d.  Scissors,  short  blunt-pointed  straight,  and  curved  on 
the  flat.  e.  Probe.  /.  Blunt  dissectors,  g.  Sharper  blunt  dissector,  h.  Aneurism 
needle,  i.  Grooved  director.  /.  Small  scoop,  h.  Needles  and  catgut.  I.  Horsehair. 
TO.  Single-  and  two-tined  tenacula.  n.  Small  hooked  and  blunt-pointed  retractors. 
Wipers,  ligatures,  drainage  agents,  large  retractors,  and  ample  gauze  and  plaster-of- 
Paris  bandages  are  needed. 

The  incisions  for  the  removal  vary  in  accordance  with  the  situation  and 
extent  of  the  glandular  involvement,  the  importance  of  the  contiguous  anat- 
omy, and  the  liability  to  operative  disfigurement.  The  transversely  directed 
skin  fold  at  the  upper  part  of  the  neck  suggests  the  site  of  an  incision  to 
obviate  deformity  in  the  removal  of  glands  located  opposite  to  the  hyoid 
bone  and  anterior  to  the  sterno-mastoid  muscle.  The  glands  in  the  lower 
part  of  the  posterior  triangle  can  be  well  approached  through  a  sigiilar 
incision  at  that  situation.  At  other  situations  oblique  incisions  arranged 
to  conform  to  the  anterior  or  posterior  border  of  the  sterno-mastoid  are 
advisable.  The  S-shaped  incision  of  Hartley  (Fig.  895),  employed  as  a 
whole  or  in  part,  as  circumstances  require,  is  a  commendable  one.     In  all 


OPERATIONS  ON  THE  NECK.  Y29 

instances  the  incision  should  be  made  sufficiently  free  to  afford  ample  room. 
Safety  of  execution  should  not  be  exchanged  for  cosmetic  result.  The 
patient  should  be  placed  upon  the  back,  with  the  shoulders  raised  and  the 
head  turned  to  the  opposite  side.  A  good  light,  plenty  of  time  and  assist- 
ance, and  aseptic  detail  should  be  at  the  command  of  the  operator.  Chlo- 
roform or  A.  C.  E.  mixture  should  be  given  to  avoid  congestion  of  the  ves- 
sels, unless  contraindicated. 

The  Ojjeration  (Treves). — Make  a  free  incision  along  the  selected  line 
through  the  skin,  platysma,  and  fascia,  avoiding  the  division  of  the  super- 
ficial nerves,  if  possible ;  expose  and  free  the  sterno-mastoid  muscle  and 
hold  it  aside  with  retractors  when  in  the  field  of  operation ;  divide  the  mus- 
cular fibers  to  a  limited  extent,  and  then  only  when  necessary ;  divide  the 
deep  fascia  and  expose  the  capsules  of  the  enlarged  glands ;  turn  out  the 
glands  with  the  handle  of  the  scalpel  or  a  similarly  shaped  implement,  if 
they  be  non-adherent ;  if  adherent,  attack  the  aggregation  at  the  point  least 
firmly  fixed,  keeping  close  to  the  cajDsules  throughout  the  dissection,  and 
removing  adherent  portions  of  the  same ;  dissect  out,  rather  than  tear  out 
a  mass  of  tissue,  as  the  latter  procedure  ruptures  the  connective  vessels, 
the  nerves,  and  also  the  capsules,  smearing  the  tissues  with  the  disorgauized 
gland  structure ;  relax  and  examine  constricting  bands  of  tissue  before  divi- 
sion, as  they  may  contain  vessels,  nerves,  etc.,  and  when  in  doubt  regarding 
the  presence  of  the  former  divide  the  tissue  between  constricting  agents ; 
isolate  torn  vessels,  and  tie  above  and  below  the  rent  with  catgut ;  search 
carefully  for  isolated  and  deep-seated  glands,  leaving  none  behind,  unless 
their  removal  as  a  whole  begets  unwarranted  danger,  and  in  such  as  these 
divide  the  capsule  and  dig  away  the  contents,  removing  the  capsule  after- 
ward, if  practicable;  flush  out  the  wound  with  an  antisej)tic  solution,  remov- 
ing blood  clots  and  arresting  all  bleeding  points ;  close  the  wound  with  deep 
and  superficial  sutures,  eradicating  all  dead  spaces;  introduce  drainage  in 
deep  wounds,  those  with  lacerated  borders,  and  in  any  in  which  diseased 
tissue  remains  behind ;  apply  antiseptic  dressings  with  overlying  sponges 
for  compression,  bandaging  them  as  firmly  in  place  as  the  respiratory  and 
circulatory  functions  of  the  neck  of  the  patient  will  permit. 

The  Precautions. — Avoid  rupturing  the  diseased  glands,  as  consequent 
infection  of  contiguous  freshened  surfaces  may  follow.  In  such  instances 
careful  cleansing  should  be  practiced  at  once.  Incautious  attention  and 
indifference  to  anatomical  details  during  removal  of  these  glands  leads  to 
unnecessary  division  of  the  superficial  nerves,  especially  the  superficial  cer- 
vical. This  nerve  passes  across  the  neck  on  either  side,  nearly  opposite 
the  thyroid  cartilage.  The  sj^inal  accessory  is  exposed  in  operations  at  the 
upper  part  of  the  posterior  triangle,  but  can  be  readily  recognized,  when 
irritated,  by  the  causing  of  contractions  of  the  muscles  it  supplies.  The 
phrenic,  pneumogastric,  recurrent  laryngeal,  descendens  hypoglossi,  the  pri- 
mary cords  of  the  brachial  plexus,  and  the  cervical  sympathetic  nerves  are 
in  but  little  danger  except  in  extensive  involvement  of  the  deep  series  of 
glands,  or  during  removal  of  deep-seated  growths  of  a  different  nature. 
Under   similar    circumstances,   the   apices   of   the   pleural   cavities — which 


730  OPERATIVE  SURGERY. 

extend  above  the  first  rib  at  either  side  of  the  body  of  the  seventh  cervical 
vertebra,  and  higher  in  the  female  than  in  the  male — may  be  invaded.  The 
right  and  left  lymphatic  ducts  are  also  endangered  by  dissection  at  these 
situations.  The  entrance  of  air  into  the  veins  is  a  danger  to  be  apprehended 
here.  The  prevention  and  treatment  is  considered  already  on  page  123. 
"  Keep  close  to  the  capsule ;  make  no  cut  in  the  dark ;  be  chary  of  cutting 
tissues  which  are  only  seen  when  put  fully  upon  the  stretch,"  are  wise  admo- 
nitions of  Treves. 

The  effects  of  division  of  the  recurrent  laryngeal,  sympathetic,  and  com- 
mon motor  nerves  of  the  neck  are  well  understood,  and  need  no  special 
mention.  The  effect  of  division  of  one  or  both  phrenic  nerves  is  compara- 
tively so  well  illustrated  by  the  outcome  in  cases  of  crushing  attendant  on 
fracture  of  the  cervical  vertebrae  as  to  need  only  the  admonition  which  the 
latter  teach  to  impress  the  importance  of  the  maintenance  of  their  structural 
integrity.  Eegarding  the  pneumogastric  in  this  connection  one  can  do  no 
better  than  to  quote  the  conclusion  of  Parh,  uttered  in  1895,  after  an  able 
consideration  of  recorded  cases :  "  Nevertheless,  the  preponderance  of  testi- 
mony is  in  favor  of  the  comparative  safety  of  attacking  this  nerve  .when 
involved  in  disease,  and  when  too  much  other  disturbance  is  not  necessitated 
by  the  condition  which  has  caused  the  operation."  * 

If  injury  of  the  thoracic  duct  be  detected  in  time,  and  the  seat  of  the 
wound  can  be  found,  repair  may  be  made  by  means  of  interrupted  sutures, 
implantation  (page  1043),  or  size  and  ligature,  as  required.  Usually  a 
knowledge  of  the  injury  occurs  too  late  for  the  purpose,  and  even  when 
favorably  recognized,  detection  of  the  breach  in  the  duct  may  not  be  possible. 
Under  the  circumstances  direct  pressure  with  gauze  compresses  is  the  suitable 
and  usually  successful  treatment  in  both  instances.    Avoid  fatty  food. 

The  Remarks. — The  natural  intimate  association  of  the  lymphatic  struc- 
tures with  the  veins  bespeaks  the  difficulty  of  the  removal  of  the  former 
when  diseased.  The  compressed  veins  become  changed  in  their  normal 
aspects,  and  therefore  are  often  divided  in  spite  of  the  greatest  caution. 
When  a  vein  can  not  be  separated  from  a  lymphatic  enlargement,  it  should 
be  sacrificed,  except,  perhaps,  in  the  instance  of  the  internal  jugular,  when 
the  gland  should  be  removed  piecemeal  if  need  be.  Excision  (page  215)  of 
a  portion  of  this  vein  between  two  ligatures  is  justifiable  when  it  is  torn  or 
traverses  a  malignant  growth.  Normal  veins  of  a  minor  size  often  resemble 
the  largest  ones  when  compressed  by  glandular  enlargements  and  malignant 
growths.  The  sterno-mastoid  muscle  should  not  be  divided,  if  possible  to 
avoid  it,  as  marked  deformity  may  follow  imperfect  union  of  the  divided  ends. 

Hartley's  Method. — Hartley  devised,  some  time  since,  the  following  in- 
genious plan  of  approach  to  diseased  glands  of  the  neck.  The  operative 
convenience  and  the  curative  and  cosmetic  outcome  of  the  plan  are  such  as 
to  commend  its  employment.  The  following  description  is  quoted  from 
Stimson's  valuable  work  on  operative  surgery,  and  has  the  additional  worth 
due  to  Hartley's  personal  revision. 

*  Transactions  of  the  American  Surgical  Association,  vol.  xiii. 


OPERATIONS  ON  THE  NECK. 


T31 


Fig.  895. — The  removal  of  diseased  cervical  lym- 
phatic glands,  Hartley's  method,  a.  Point 
of  division  of  the  sterno  -  mastoid  muscle. 
h,  c,  d.  Line  of  incision. 


The  Operation. — The  incision  is  S-shaped  (Fig.  895),  and  involves 
only  the  skin,  subcutaneous  tissue,  and  fascia;  starting  below  the  chin  it 
passes  in  a  curve  downward  and  backward  to  the  hyoid  bone,  then  up 
behind  the  angle  of  the  jaw  to  near  the  lobule  of  the  ear,  whence  it  sweeps 
down  along  the  anterior  border 
of  the  trapezius,  forward  over 
the  sterno-mastoid,  and  down- 
ward and  backward  again  to 
terminate  above  the  middle 
of  the  clavicle  {h,  c,  d).  The 
Haps  thus  formed  are  dissected 
up,  exposing  nearly  the  whole 
length  of  the  sterno-mastoid, 
and  the  latter  is  cut  trans- 
versely near  its  center  and  the 
ends  reflected,  care  being  taken 
not  to  injure  the  spinal  acces- 
sory nerve  above.  The  point 
where  the  muscle  is  divided 
must  not  be  in  the  line  of  the 
cutaneous  incision,  but  under 
the  middle  of  one  of  the  flaps, 
preferably  the  upper  (a).     The 

great  vessels  are  thus  exposed  from  the  mastoid  process  to  the  clavicle,  and 
the  operator  can  excise  the  adherent  and  diseased  glands,  and  avoid  injury 
to  the  adjacent  important  structures. 

At  the  close  of  the  operation  the  divided  ends  of  the  sterno-mastoid  are 
united  with  catgut,  the  flaps  replaced  and  loosely  sutured  in  position,  and 
drainage  provided  for  in  the  most  dependent  angles. 

This  large  incision  is  only  used  when  the  glands  in  the  superior  and 
inferior  carotid  and  submaxillary  triangles  are  involved  simultaneously. 
For  less  extensive  disease  the  upper  or  lower  flap  may  be  employed  alone; 
or  one  may  be  fashioned  with  a  pedicle  in  a  position  the  reverse  of  that 
shown  in  the  figure.  The  incision  for  a  single  flap  should  approximately 
correspond  to  the  circumference  of  the  tumor,  which  is  then  exposed  in  its 
entirety  by  division  of  the  sterno-mastoid  below  the  point  where  it  is  entered 
by  the  spinal  accessory  nerve.  The  flap  consists  of  skin,  subcutaneous 
tissue,  platysma,  and  fascia. 

The  Johns  Hopkins  Hospital  (Mitchell)*  plan  of  practice  may  be 
briefly  expressed  as  follows : 

The  Operation. — Make  a  curved  incision  (Fig.  896)  from  over  the 
mastoid  process,  forward  along  the  anterior  border  of  the  sterno-mastoid 
muscle,  thence  slightly  backward  to  the  middle  of  the  clavicle;  make  a 
transverse  incision  along  the  upper  border  of  the  clavicle,  forming  with  the 
preceding,  a  T-shaped  outline;  dissect  back  the  skin,  uncovering  a  quad- 


*  Johns  Hopkins  Hospital  Bulletin,  July,  1902. 


T32 


OPERATIVE  SURGERY. 


Fig.  896. — Skin  incision  for  complete  removal  of  glands 
of  neck. 


rilateral  area,  through  which  all  parts  of  the  neck  can  be  easily  reached; 
divide  the  subcutaneous  fascia  and  the  platysma  of  the  angle  between  the 
posterior  border  of  the  sterno-mastoid  muscle  and  the  clavicle,  along  with 
a  few  of  the  posterior  fibres  of  this  muscle,  and  turn  the  tissues  back,  ex- 
posing the  external  jugular  vein ;  ligature,  divide,  and  turn  aside  this  vein, 
thus  exposing  the  "  key  to  the  operation  " — the  omo-hyoid  muscle ;  seize 

and  divide  the  omo-hyoid 
and  (using  the  upper 
part  as  a  retractor)  pull 
aside  the  posterior  border 
of  the  sterno-mastoid,  thus 
permitting  the  dissection 
to  be  carried  up  along 
the  internal  jugular  and 
posterior  border  of  the 
sterno-mastoid  to  the  pos- 
terior branch  of  the  spinal 
accessory;  remove  the  dis- 
eased glands  from  the 
nerve,  leaving  them  con- 
nected with  those  above, 
and  continue  the  whole 
dissection  from  the  medi- 
an line  and  below,  upward  and  outward.  In  some  mstances  the  degree  of 
involvement  of  the  spinal  accessory  and  the  sterno-mastoid  and  trapezius 
muscles  is  such  that  their  rescue  by  continued  dissection  in  this  manner  is 
practically  impossible.  In  such  cases  the  following  plan  is  practiced :  use  as 
before  the  omo-hyoid  for  a  guide  and  divide  the  sterno-mastoid  low  down  on 
a  line  with  it ;  reflect  the  ends  of  the  sterno-mastoid  upward  and  downward, 
thereby  exposing  a  large  area  and  the  anterior  and  posterior  chain  of  glands 
embracing  the  muscle  and  nerve  above;  rescue  now  both  branches  of  the 
nerve,  ligaturing  and  removing  the  internal  jugular  if  required.  In  some 
instances  the  disease  may  be  so  extensive  as  to  require  removal  of  some 
portions  of  the  sterno-mastoid  and  trapezius  muscles.  The  ends  of  the 
divided  muscles  should  be  sutured  and  their  functions  favored  until  repair 
is  completed;  when  removed,  deeper  muscles  assume  the  functions.  The 
wounds  are  closed  with  subcuticular  silver  sutures,  temporary  drainage 
provided,  abundance  of  gauze  applied,  and  strict  immobility  enforced  by 
plaster-of-paris  bandages  supplemented  with  three  box-wood  splints  em- 
bracing the  head  and  shoulders. 

The  Remarhs. — The  disease  is  usually  descending,  because  of  the 
oral  sources  of  the  infliction-  MitcJiell  recalls  the  facts  that,  practically 
speaking,  the  lymph  glands  of  the  neck  may  be  divided  into  four  groups: 
"  Those  in  the  anterior  triangle  and  those  in  the  posterior,  with  two  con- 
necting chains,  one  passing  in  front  and  the  other  behind  the  sterno-mastoid 
muscle."  The  chain  behind  the  muscle  appears  to  be  the  most  commonly 
involved,  hence  arises  much  of  the  difficulty  of  the  operation  for  removal. 


OPERATIONS  ON  THE  NECK.  Y33 

The  superior  triangle  is  involved  in  70  per  cent  of  the  cases,  and  the 
disease  is  more  extensive  here  than  elsewhere  in  the  neck  when  its  other 
regions  are  implicated.  By  the  p'receding  method  the  internal  jugular  is 
exposed  at  its  lowest  portion  at  the  heginning  of  the  operation,  and  can  be 
provisionally  tied  to  prevent  entrance  of  air  if  injured  later.  The  most 
difficult  part  of  the  operation  is  with  the  chain  of  glands  connecting  those 
of  the  anterior  and  posterior  triangles  behind  the  sterno-mastoid  muscle 
at  the  seat  of  the  spinal  accessory  nerve,  with  which  the  nerve  is  some- 
times perplexingly  involved,  and  great  care  and  patience  is  often  needed  to 
safely  rescue  it  from  the  diseased  investment.  Some  of  the  branches  of  the 
cervical  plexus  are  necessarily  divided,  but  the  descendens  noni  and  the 
phrenic  should  always  escape,  especially  the  latter.  Carefully  avoid  the 
thoracic  ducts ;  if  cream  be  given  before  the  operation  the  injury  is  more 
easily  detected  (Allen  and  Biggs).  Perpendicular  scars  spread  and  become 
more  conspicuous.  Transverse  ones  diminish  in  conspicuousness,  there- 
fore the  vertical  should  be  short  and  be  placed  on  living  surfaces  when 
possible,  and  the  transverse  should  follow  the  folds  of  the  neck.  However, 
cosmetic  considerations  ought  not  to  supersede  curative  means. 

The  After-treatment. — The  after-treatment  in  these  operations  consists 
in  securing  the  complete  local  rest  consistent  with  the  proper  cleanliness 
of  the  wound.  Fluids  should  be  given,  and  movements  of  the  lower  jaw 
interdicted.  The  drainage  should  be  removed  in  a  day  or  two,  except  when 
diseased  products  are  present.  The  sutures  are  taken  out  in  seven  or  eight 
days;  the  buried  ones,  of  course,  remain. 

The  Results. — In  128  cases  operated  on  by  Billroth,  91  healed  by  primary 
union,  25  suppurated,  and  erysipelas  developed  in  5.  In  49  the  final  result 
could  not  be  obtained.  In  24  per  cent  no  recurrence  appeared  in  three  and 
a  half  years.  Local  relapse  happened  in  14  per  cent,  and  in  4  per  cent  at 
points  distant  from  the  seat  of  operation.  In  16  cases  the  internal  jugular 
was  tied. 

The  Results. — The  dangers  of  operation  are  slight;  shock  does  not 
characterize  it.  Jordan  and  Bios  report  328  cases  without  a  death.  Tran- 
sient tachycardia  and  occasional  hgemorrhage  follow;  local  recurrence  hap- 
pened in  from  7  (Mitchell)  to  30  (Bios)  per  cent. 

Branchial  Cysts. — Branchial  cysts  are  of  congenital  origin  and  should 
be  removed  as  early  in  their  history  as  practicable.  Their  frequent  intimate 
association  with  the  important  deep  structures  of  the  neck  invest  their  treat- 
ment Avith  especial  concern.  Not  infrequently  a  somewhat  superficial  cyst 
of  this  nature  is  connected  deeply  by  means  of  a  long,  narrow,  devious  tract, 
the  discovery  and  eradication  of  which  is  necessary  to  a  final  cure.  The 
steps  of  the  operative  removal  of  these  morbid  developments  differ  in  no 
essential  respect  from  those  directed  to  the  treatment  of  diseased  glands. 
The  frequent  greater  profundity  of  the  former  is  offset  by  the  extensive 
morbid  changes  of  the  latter,  so  far  as  operative  technique  is  concerned. 
The  introduction  of  a  probe  along  the  channel  to  the  seat  of  origin  is  often 
advantageous  in  the  treatment  of  this  variety  of  cases.  In  the  instance  of 
removal  from  the  neck  of  other  tumors  than  the  special  ones  already  con- 


T34 


OPERATIVE  SURGERY. 


sidered,  the  rules  of  technique  applicable  to  the  latter  can  be  satisfactorily 
applied  to  the  removal  of  the  former  class.  Briefly  stated,  free  exposure 
of  the  growth  through  an  incision  best  suited  to  the  purpose;  the  removal 
by  cautious  blunt  dissection,  attended  with  prompt  control  of  bleeding 
points ;  the  prevention  of  air  thrombosis ;  and  the  preservation  of  important 
structures. 

The  Extirpation  of  the  Parotid  Gland. — The  complete  removal  of  this 
gland  is  a  most  difficult  operation,  especially  when  its  relations  are  changed 
by  a  malignant  growth  implicating  its  structure. 


Horizontal  section. 


Fig.  897.— The  parotid 
The  ramus  of  the  lower  jaw.    2.  The       1. 
styloid    process  and  its  muscles.     3. 
The  masseter  muscle.    4.  The  internal 
pterygoid    muscle.     5.   The    digastric 
muscle.    6.  The  sterno-raastoid  muscle. 

7.  The  superficial  parotid  aponeurosis. 

8.  The  deep  parotid  aponeurosis.  9. 
The  wall  of  the  pharynx.  10.  The 
pharyngeal  orifice  of  the  parotid 
sheath.  11.  The  internal  carotid  ar- 
tery. 12.  The  internal  jugular  vein, 
13.  The  integument.  I4..  The  subcu- 
taneous tissue.  15.  The  facial  nerve. 
16.  The  temporo-maxillary  vein.  17. 
The  external  carotid  artery. 


Frontal  section. 


compartment. 

The  external  auditory  meatus.  2.  The 
skull.  3  and  4.  The  styloid  process  and 
its  muscles.  5.  The  superficial  parotid 
aponeurosis.  6.  The  deep  parotid  apo- 
neurosis. 7.  The  junction  of  inferior 
parts  of  compartment.  8.  The  situa- 
tion of  the  pharyngeal  orifice.  9.  The 
internal  carotid  artery.  10.  The  inter- 
nal jugular  vein.  11.  The  external 
carotid  artery.  12.  The  external  jugu- 
lar vein.  13.  The  integument.  14..  The 
subcutaneous  tissue. 


The  Anatomical  Points. — The  parotid  gland  is  located  in  the  parotid 
compartment,  which  is  formed  by  the  cteep  cervical  fascia;  it  is  trabecu- 
lated,  and  is  bounded  in  fro?it  by  the  posterior  border  of  the  ramus  of  the 


OPERATIONS  ON  THE  NECK.  735 

lower  jaw  and  its  associated  masseter  and  internal  pterygoid  muscles 
(Fig.  SOT,  Horizontal  section)  ;  behind  by  the  sterno-mastoid,  the  posterior 
belly  of  the  digastric  muscles,  and  the  mastoid  process ;  above  by  the  external 
auditory  meatus  and  the  posterior  part  of  the  glenoid  fossa;  belotv  by  the 
stylo-maxillary  ligament  separating  the  parotid  from  the  posterior  extremity 
of  the  submaxillary  gland;  internally  by  the  styloid  process  and  its  attached 
muscles  separating  the  gland  behind  from  the  internal  carotid,  the  internal 
jugulars,  and  their  accompanying  nerves;  in  front  from  the  loose  sub- 
pharyngeal  tissue.  The  external  layer  and  the  internal  layer  of  the 
sheath  of  the  sterno-mastoid  correspondingly  surround  the  parotid,  meet- 
ing at  its  anterior  border,  thus  forming  chiefly  the  sheath  or  compart- 
ment of  the  gland.  This  sheath  is  incomplete  (Fig.  897,  10,  Horizontal  sec- 
tion) at  the  inner  aspect  in  front  of  the  styloid  process,  corresponding  to  the 
pharyngeal  wall,  therefore,  the  pharynx  and  the  gland  are  not  infrequently 
reciprocally  involved  in  disease  of  either  of  these  regions.  Also  this  sheath 
is  not  complete  above  corresponding  to  the  external  ear  (Fig.  897,  Frontal 
section),  accounting  for  the  readiness  with  which  inflammations  of  the  glantl 
invade  the  auricular  region  at  this  situation.  Extension  of  the  head  and 
protrusion  of  the  jaw  increase  somewhat  the  access  to  the  compartment  in 
old  age.  In  infancy  the  jaw  encroaches  the  least  upon  the  superficial  area 
of  the  parotid  compartment.  A  careful  study  of  the  anatomy  of  this  gland 
and  its  environments  should  precede  all  efforts  directed  to  its  removal. 
Elongations  of  the  gland  of  considerable  size  extend  from  its  deep  surface 
inward,  one  in  front  of  and  the  other  behind  the  styloid  process,  the  former  ^, 
passing  behind  the  mastoid  process  and  sterno-mastoid  muscle,  the  latter-to 
the  back  part  of  the  glenoid  fossa.  The  external  carotid  arterj  passes 
through  the  gland  from  below  upward,  dividing  into  its  terminal  branches 
before  its  escape.  Superficial  to  this  artery  there  is  a  venous  trunk  formed 
by  the  union  of  the  temporal  and  internal  maxillary  veins  (Fig.  897,  16 
and  17,  Horizontal  section)  ;  to  this  trunk  the  internal  jugular  is  con- 
nected by  a  small  branch  that  passes  through  the  gland  structure.  The 
facial  nerve  (15)  and  its  branches  traverse  the  gland  from  behind  forward, 
and  receive  a  communicating  branch  from  the  great .vuricular  in  its  sub- 
stance. Immediately  beneath  the  floor  of  the  space  lie  the  internal  carotid 
artery  and  internal  jugular  vein,  along  with  the  spinal  accessory,  glosso- 
pharyngeal, and  pneumogastric  nerves.  Lymphatic  glands  lie  over  the 
parotid  and  are  present  within  it,  and  their  enlargement  may  be  mistaken 
for  that  of  the  gland  itself. 

The  Contraindications  to  Extirpation. — Immobility  of  the  tumor  and 
a  malignant  growth  implicating  the  structure  of  the  gland  may  be  regarded 
as  strong  contraindications  to  operation. 

The  Operation. — Place  the  patient  upon  a  suitable  table  in  a  good  light, 
with  the  shoulders  elevated  and  the  head  turned  to  the  opposite  side.  Make 
an  incision  from  the  zygoma  downward  along  the  central  line  of  the  tumor 
to  its  lower  border.  If  necessary,  this  one  can  be  supplemented  by  one  or 
more  extending  from  it  at  right  angles.  The  integumentary  flaps  are  freely 
reflected  to  expose  the  growth.     The  tumor  should  be  raised  from  below 


736 


OPERATIVE  SURGERY. 


upward,  and  held  b}^  a  volsella.  This  will  raise  the  external  carotid  from  its 
bed,  when  it  should  be  isolated,  tied  between  two  ligatures,  and  divided. 
The  vessels  that  enter  or  escape  from  the  tumor  at  this  point  should  be 
treated  in  the  same  manner  (Fig.  898).  The  tumor  can  now  be  raised 
upward,  and  its  separation  from  the  deeper  tissues  continued  by  means  of 


Pig.  898. — The  surgical  anatomy  of  the  parotid  gland. 


the  fingers  or  handle  of  the  scalpel ;  the  former  are  the  better.  The  vessels, 
as  they  appear  in  the  course  of  the  dissection,  are  isolated  and  cut  between 
two  ligatures. 

The  separation  of  the  growth  from  the  floor  of  the  space  must  be  done 
gently  and  with  great  caution  on  account  of  the  contiguity  of  the  internal 
jugular  vein  and  the  other  important  vessels,  and  the  nerves  located  there, 
which,  if  the  growth  be  a  large  one,  will  be  pressed  upon  by  it,  and  may 
have  become  adherent  to  it.  It  is  scarcely  possible  to  avoid  division  of  the 
facial  nerves  if  the  growth  be  compact.  If  it  be  soft  and  spongy,  the  integ- 
rity of  the  nerve  may  be  preserved  by  a  careful  use  of  the  fingers  or  director. 
The  upper  extremity  of  the  gland  is  last  removed.  This  step  of  the  opera- 
tion is  necessarily  attended  with  considerable  hgemorrhage,  which  is,  how- 
ever, easily  controlled.  After  the  removal,  unite  the  flaps,  establish 
drainage,  and  dress  antiseptically.  During  the  dissection,  room  can  be 
gained  by  causing  the  patient  to  open  the  mouth.  Some  tumors  of  large 
size,  without  adhesions,  are  more  easily  removed  than  small  adherent 
tumors.  When,  as  one  approaches  the  large  vessels,  the  adhesions  become 
more  resistant,  great  caution  should  be  exercised,  as  the  important  struc- 
tures may  be  closely  adherent  to  the  tumor.     If,  then,  further  efforts  to 


OPERATIONS  ON  THE  NECK.  737 

separate  the  tumor  be  unwise,  the  separated  portion  shoukl  be  cut  away 
and  the  remainder  left  in  space.  Often  under  these  circumstances  the 
remaining  portion  becomes  with  increasing  growth  more  superficial,  when 
it  can  be  removed.  The  division  and  turning  aside  the  ramus  of  the 
jaw  has  been  done  in  some  instances  to  gain  more  room.  The  limited  space 
in  which  the  gland  is  located  leads  to  early  adhesions  at  its  important 
aspects.  Preliminary  ligature  of  the  external  carotid  lessens  the  amount 
of  the  bleeding  from  the  arteries  directly  concerned  in  the  operation. 
Eespiratory  aspiration  exercises  its  influence  on  the  veins  involved  in  the 
operation. 

The  Results. — This  operation  has  been  done  upward  of  200  times. 
When  performed  for  malignant  growths,  the  disease  has  almost  invariably 
returned  within  six  months.  The  dangers  to  life  from  the  operation  itself 
are  about  12  per  cent;  only  a  few  cases  of  cure  of  malignant  disease  are 
reported. 


INDEX. 


Abbe's  method  of  controlling  hsemor- 
I'hage  in  operation  on  superior  maxil- 
lary nerve,  2S3;  method  of  intracranial 
neurectomy  of  trifacial  nerve,  306; 
method  of  intracranial  neurectomy  of 
trifacial  nerve,  remarks  on,  306;  opera- 
tion for  stricture  of  cesophagus,  675. 

Abdominal  aorta,  contiguous  anatomy  of, 
130;  compression  of,  5-40;  ligature  of, 
130. 

Abdominal  injury,  shock  due  to,  120, 

Abdominal  wall,  weak  point  in,  141. 

Abscess,  cerebellar,  260;  cerebral,  258; 
of  neck,  725;  of  tonsil,  634;  retrophar- 
3'ngeal,  726;  retropharyngeal,  Buck- 
hardt's  method  of  opening,  727 ;  retro- 
pharyngeal, Chiene's  method  of  open- 
ing, 726. 

A.  C.  E.  mixture,  10-31;  indications  for, 
32. 

Acid,  boric,  saturated  solution,  61 ;  car- 
bolic, 60;  carbolic,  for  instruments,  52; 
carbolic,  injection  of,  in  goitre,  Senn, 
722;  carbolic,  with  oleaginous  sub- 
stances, 60;  oxalic,  in  cleansing  hands, 
114;  salicylic,  61;   sulphurous,  61. 

Acquired  deformities,  558. 

Acromion  process  of  scapula,  excision  of, 
382. 

Actual  cautery,  79. 

Acupressure,  75;  applied  to  varicose  veins, 
216;   Simpson's  method,  75. 

Acute  hydrocephalus,  229;  lumbar  punc- 
ture in,  229;  results  of  operation  on, 
229. 

Adams's  operation  for  Dupuytren's  con- 
traction, 351;  results,  351;  saw,  433; 
subcutaneous  division  of  the  neck  of 
the  femur,  436. 

Adductor  longus,  tenotomy  of.  337. 

Adhesive  strips  in  treatment  of  operation 
wound,  97, 

Adrenalin,  241 :  during  shock.  122. 

Adrenalin  chloride,  60;  Crile  on  action  of, 
67 ;  methods  of  administration  of,  67. 

Agents  for  control  of  htpmorrhage,  65. 

Agnew's  method  of  flap  formation  in  am- 
putations of  thigh,  535;  operation  for 
salivary  fistula,  632;  operation  for 
webbed  fingers,  566, 

48 


Air  in  veins,  122;  Kemp's  treatment  of, 
124;  preventive  treatment  of,  124; 
symptoms  of,  122;  treatment  of,  122, 

Air  passages,  foreign  bodies  in,  698;  com- 
ments on,  699;  results  of,  700;  treat- 
ment of,  699. 

Alcohol,  62;  hypodermics  of,  14;  in  prep- 
aration of  field  of  operation,  95;  in 
sterilizing  and  preserving  sutures,  91. 

Alcoholic  patients,  operations  on,  0. 

Alexander's  method  of  ligaturing  verte- 
bral artery,  176. 

AUis's  inhaler,  25. 

Alum  as  a  styptic,  68, 

Alveolar  process  of  lower  jaw,  excision 
of,  376, 

Ammonia,  119;  for  cleansing  the  hands, 
114, 

Amputating  knife,  manner  of  grasping 
the,  462;  knives,  461;  knives,  the  Cat- 
lin,  462, 

Amputating  saws,  464;  proper  method  of 
using,  464, 

Amputation,  agents  required  for,  461; 
aims  sought  in,  451;  circular  method, 
453;  circular  method  modified,  456-, 
double-flap  method,  457;  equilateral 
flaps,  458;  flaps,  451,  452;  hood  flap, 
458;  Langenbeck's  method,  458:  mixed 
double  flap,  Sedillofs  method,  457; 
oval  or  racket  method,  456;  periosteal 
flap,  459;  rectangular  flap,  Teale's 
method,  458;  retra'ctors  used  in,  460; 
semilunar  flaps,  Liston's,  450;  selection 
of  method  of,  400;  single  flap  method 
of,  450;  stump,  451, 

Amputation  above  shoulder  joint,  492; 
Berger's,  492;  comments  on,  494;  pre- 
cautions for,  494 ;  results  of,  495, 

Amputation  at  ankle  joint,  fallacies  of, 
511;  modification  of  Syme's,  510; 
Eoux's  method,  512;  Roux's  method, 
remarks  on,  512;  Syme's  method,  509; 
Svme's  method,  results,  512;  Wyeth's, 
511, 

Amputation  at  astragalus,  Hancock's,  .508, 

Amputation  at  carpo-metacarpal  articu- 
lation of  thumb,  little,  and  index  finger, 
473;  oval  method,  473;  lateral-flap 
method,  475, 


u 


INDEX. 


Amputation  at  elboAV  joint,  481 ;  anatom- 
ical points  for,  481;  anterior  singie-Hap 
method,  482;  comments  on,  483;  circu- 
lar methodj  482;  elliptical-flap  meth- 
ods, 481;   results  oi,  483. 

Amputation  at  finger,  469. 

Amputation  at  hip  joint,  540;  anterior 
racket  method,  550 ;  antero-posterior- 
llap  method,  Guthrie's,  555;  bloodless, 
Senn's,  546;  circular-flap  method,  Dief- 
fenbach's,  552;  control  of  haemorrhage 
in,  73,  540;  external  racket  method, 
549;  external  racket  method.  Lister's 
modifleation,  550;  Furneaux- Jordan 
method,  554;  Lloyd's  method  of  con- 
trolling haemorrhage  in,  545;  long  an- 
terior and  short  posterior-flap  method, 
Manec's,  551;  McBurney's  method  of 
controlling  haemorrhage  in,  545;  meth- 
ods of,  549;  results,  546,  557;  shock 
after,  546;  single  flap,  Malgaigne's, 
555;  Tilden  Brown's  clamp  for  con- 
trolling haemorrhage  in,  546;  tourni- 
quet for  control  of  haemorrhage  in,  540 ; 
treatment  after,  557;  Trendelenburg's 
rod  in,  542;  Wyeth's  method  of  con- 
trolling haemorrhage  in,  542. 

Amputation  at  knee  joint,  523;  anatom- 
ical points  for,  524;  bilateral-flap  meth- 
od, Stephen  Smith's,  524;  fallacies  of 
bilateral-flap  method,  Stephen  Smith's, 
525;  precautions  in  bilateral-flap  meth- 
od, Stephen  Smith's,  525;  circular-flap 
method,  526;  elliptical  incision  meth- 
od, Baudens's,  526;  long  anterior  and 
short  posterior-flap  method,  Pollock's, 
527;  methods  of,  524;  results  of,  527; 
Stephen  Smith's  method  for  gangre- 
nous condition  of  toes- and  foot,  525. 

Amputation  at  the  medio-tarsal  joint, 
Chopart's,  504 ;  remarks  on,  505 ;  results 
of,  505;  Forbes's  modification  of  Cho- 
part's, 505. 

Amputation  at  metacarpo-phalangeal  ar- 
ticulation, 471;  by  lateral-flap  method, 
472;  by  oval-flap  method,  471;  of  second 
and  third  fingers,  471. 

Amputation  at  metatarso-phalangeal  ar- 
ticulation of  all  toes,  499 ;  comments  on, 
500 ;  results  of,  500. 

Amputation  at  phalangeal  articulation, 
hand,  469;  anatomical  points  for,  469. 

Amputation  at  phalangeal  articulation, 
second  row,  finger,  470. 

Amputation  at  phalanx,  terminal,  finger, 
469. 

Amputation  at  shoulder  joint,  486;  cir- 
cular incision  method,  489 ;  circular  in- 
cision method,  remarks  on,  489 ;  exter- 
nal- and  internal-flap  method,  Dupuy- 
tren's,  488;  oval-flap  method,  Larrey's, 
491 ;  prevention  of  haemorrhage  in,  487 ; 
racket-flap  method,  Spence's.  491 ;  re- 
marks on,  492;  results  of,  492;  special 
considerations  for,  487 ;  Wyeth's  needles 
in,  487. 


Amputation  at  tarso-metatarsal  joints,  ;' 
Baudens's  modification  of  Lisfranc's, 
504;  Hey's  modification  of  Lisfranc's, 
504;  Lisfranc's,  502;  Lisfranc's,  remarks 
on,  504;  Skey's  modification  of  Lis- 
franc's, 504;  Smith's  modification  of 
Lisfranc's,  504. 

Amputation  at  wrist,  477;  anatomical 
points  for,  477;  circular-fiap  method, 
477;  double-flap  method,  Ruysch's,  478; 
radial  flap,  Dubrueil's,  479;  remarks, 
479;  results,  479;  single  palmar  flap, 
478. 

Amputation  of  arm,  483;  antero-pos- 
terior-flap  method,  484;  circular-flap 
method,  483;  irregular  double-flap 
method,  484;  irregular  double-flap 
method,  remarks  on,  484;  large  ante- 
rior and  small  posterior  skin-flap  meth- 
od, 485;  musculo-cutaneous  flaps  in, 
Langenbeck's,  484;  Teale's  method, 
485. 

Amputation  of  arm  at  surgical  neck  of 
humerus,  485;  anatomical  points  for, 
485;  oval  method,  Guthrie's,  486;  sin- 
gle external-flap  method,  Farabeuf's, 
486;  remarks  on,  486;  results  of, 
486. 

Amputation  of  foot,  Bruns's,  515;  Es- 
march's  modification  of  Le  Fort's,  515; 
Fergusson's  modification  of  Pirogoft"'s, 
513;  Le  Fort's  modification  of,  Piro- 
goflf's,  514;  Pirogoff's,  512;  Pirogoff''s, 
remarks  on,  513;  Pirogoff's,  results  of, 
513;  results  of,  515. 

Amputation  of  forearm,  479;  anatom- 
ical points  for,  479;  circular  skin-flap 
method,  479;  comments  on,  481;  equi- 
lateral skin-flap  method,  480;  Jacob- 
son's  posterior  flap  in,  480;  musculo- 
cutaneous-flap  method,  480;  results  of, 
481. 

Amputation  of  great  toe,  498 ;  by  square- 
flap  method,  498;  flrst  phalanx,  496- 
497;  or  little  toe,  498;  or  little  toe,  in- 
ternal plantar  flap-method  of  Farabeuf, 
499 ;  or  little  toe,  oval-flap  method,  499 ; 
through  last  phalanx,  497. 

Amputation  of  great  toe  with  metatarsal 
bone,  501. 

Amputation  of  leg,  lower  third,  author's 
circular,  with  periosteal  flap,  516;  au- 
thor's circular,  with  periosteal  flap,  re- 
marks on,  517;  author's  circular,  with 
periosteal  flap,  results  of,  518;  Duval's 
supramalleolar,  516;  Guyon's  supra- 
malleolar, 516;  methods  of,  516;  results 
of,  520;  Teale's  method,  518;  with  bi- 
lateral flaps,  519;  with  hood  flap,  520; 
with  large  posterior  flap,  518. 

Amputation  of  leg  at  middle  third,  520; 
large  posterior-flap  method,  Hey's,  520; 
Lee's  modification  of  Teale's,  521 ;  long 
external-flap  method,  521;  results  of, 
521. 

Amputation  of  leg  at   upper  third,  521; 


INDEX. 


m 


bilateral-flap  or  hood  method,  523 ;  eir- 
cular-llap  method,  522;  large  external- 
flap  method,  Farabeuf's,  521;  results, 
523. 

Amputation  of  leg,  osteoplastic,  P)ier's, 
530;  Eiselberg's,  530. 

Amputation  of  leg,  treatment  after,  523. 

Amputation  of  metacarpal  bones,  four, 
with  fingers,  47G;  inner  three,  470;  last 
four,  475;  last  two,  470. 

Amputation  of  metatarsal  bone  of  sec- 
ond, third,  or  fourth  toe,  502;  com- 
ments on,  502. 

Amputation  of  phalanges,  fingers,  re- 
marks on,  470. 

Amputation  of  thigh,  532 ;  Agnew's  meth- 
od of  flap  formation  in,  535;  antero- 
posterior musculo-integumentary  flap 
method,  534;  bilateral-flap  method, 
533;  circular  integumentary  flap  meth- 
od, 535;  circular  integumentary  flap 
method,  Syme's  modification  of,  535 ; 
equilateral-flap  method,  Vermale's,  533 ; 
general  remarks  on,  537 ;  long  anterior 
and  short  posterior-flap  method,  Fara- 
beuf's, 537 ;  long  anterior-flap  method, 
Sedillot's,  537 ;  methods  of,  533 ;  results 
of,  540;  single  circular  incision  method, 
Celsus's,  530;  single  circular  incision 
method,  Celsus's,  remarks  on,  537;  spe- 
cial considerations  for,  532;  suturing 
over  the  ends  of  bone  after,  537 ;  treat- 
ment after,  539. 

Amputation  of  thigh  through  condyles, 
528;  Garden's  method,  528;  Garden's 
method,  results,  528;  Farabeuf's  meth- 
od, 529;  Gritti's  osteoplastic  method, 
529;  Gritti's  osteoplastic  method,  falla- 
cies of,  529;  Lister's  modiflcation  of 
Garden's  method,  528;  iSabanejett"s  os- 
teoplastic method,  532 ;  Stokes's  modifl- 
cation of  Gritti's  method,  529;  results 
of  ytokes's  and  Gritti's  method,  530. 

Amputation  of  thigh  through  trochan- 
ters, 540. 

Amputation  of  toes,  little,  498 ;  little,  with 
metatarsal  bone,  501 ;  phalanges  of, 
499 ;  second,  third,  and  fourth,  497 ; 
single,  497;  two  adjoining,  499. 

Amputation,  substragaloid,  500;  Ligne- 
rolles's,  507;  Lignerolles's,  results  of, 
508;  heel-flap  method,  508;  Verneuil's, 
508. 

Amputation,  tarsal,  irregular,  Molliere's, 
500. 

Amputation  through  metacarpal  bones, 
475;  remarks  on,  475. 

Amputation  through  metatarsal  bones, 
500. 

Am])utation  through  os  calcis,  Tripier's, 
508. 

Amputations  at  leg,  515. 

Amputations  at  lower  extremity,  duty  of 
surgeon,  490. 

Amputations  at  upper  extremity,  general 
remarks  on,  408. 


Amputations,  comments  on,  407 ;  general 
consi(k'ration  of,  451. 

Amputations  of  tliunib  and  fingers,  re- 
marks on,  477;   results  of,  477. 

Anipulations,  tarsal,  results  of,  509; 
treatment  after,  509. 

Amyl  nitrite;,  119;  during  sliock,  122. 

Ana;sthesia,  administration  of  oxygen 
during,  35;  coughing  and  swallowing 
under,  12;  dangers  of,  10;  during  oper- 
ations on  tongue,  035;  fancies  during, 
14,  15;  for  excision  of  upper  jaw,  305; 
for  operation  on  cervical  lymphatic 
glands,  729;  for  operation  on  thyroid 
body,  711,  710;  for  removal  of  nasal 
growths,  GOO;  for  removal  of  nasal 
polyi^i,  051;  for  removal  of  tonsil,  033; 
hypodermic  injections  during,  14;  in 
gunshot  wounds  of  the  cranium,  200 ;  in 
staphylorrhaphy,  020;  in  tuberculosis, 
5;  incomplete,  dangers  of,  10;  infiltra- 
tion, with  cocain  (Schleich),  38;  in- 
struments for,  13;  intraneural,  38;  lar- 
jnigeal  obstruction  during,  10;  muscles 
during,  15;  preparation  of  patient  for, 
10;  pulse  during,  14;  pupils  during, 
15;  pushing  jaw  forward  during,  15; 
reflexes  as  guides  during,  15;  regional 
paraneural  infiltration,  38;  respiration 
during,  14,  15;  spinal,  41;  stimulants 
during,  14;  struggling  of  patients  un- 
der, 11;  sulTocation  from  vomited  mat- 
ter during,  120;  through  tracheotomy 
tube,  000. 

Anaesthetic  for  bronchotomy,  682;  for 
laryngotomy,  028;  for  tracheotomy, 
682;  in  craniotomy,  250;  in  intubation 
of  larynx,  696;  rapid  respiration  as  an, 
36. 

Anaesthetics,  A.  C.  E.  mixture,  31;  chlo- 
roform, 28;  chloroform  before  ether,  34; 
chloroform  mixtures  before  ether,  34; 
choice  of,  4,  10,  23,  34;  dangers,  of,  15; 
deaths  from,  22;  ether,  23;  ethyl  bro- 
mide, 34;  ethyl  chloride,  34;  gas  before 
ether,  34;  inebriation  before,  35;  mor- 
phine with,  35;  nitrous  oxide,  32;  ni- 
trous oxide  with  oxygen,  33;  Schleich 's 
mixture,  38;  local,  36. 

Anaesthetist,  duties  of,  14,  93  ;  equipment 
of,  13;  one  assistant  necessary  as  an, 
93;  preparation  of,  12. 

Anatomical  giiide,  contiguous,  to  an 
artery,  125. 

Anatomical  points  of  lingual  or  gusta- 
tory nerve,  288. 

Anchylosis,  bony,  of  knee  joint,  441;  gen- 
eral remarks  on  osteotomy  for,  441 ; 
osteotomy  for,  441. 

Anderson's  method  of  lengthening  tendo- 
Achillis,  341. 

Aneui'ismal  needle  in  amputating,  467. 

Aneurism,  extirpation  of,  202;  fusiform, 
radical  cure  of,  207;  needle,  129;  nee- 
dle in  ligature  of  arteries,  127:  of  the 
extremities,  200;  of  the  extremities,  ex- 


IV 


INDEX. 


tirpation  of,  206;  of  the  extremities, 
ligature  of  collateral  branches  of,  206; 
of  the  extremities,  remarks  on  extirpa- 
tion of,  207;  radical  cure  of,  Matas's 
method,  207 ;  remarks  on  Matas's  meth- 
od of  radical  cure  of,  209;  sacciform, 
radical  cure  of,  208;  spontaneous  sub- 
clavian, 203;  traumatic,  202. 

Anger's  operation  for  ingrown  toe-nail, 
567. 

Angina,  Ludwig's,  725. 

Angular  incision  for  goitre,  714. 

Angular  gyrus,  250. 

Angular  nose,  595. 

Ankle-joint  amputation,  509;  modifica- 
tions of  Syme's  method,  510;  Roux's 
method,  512;  Roux's  method,  remarks 
on,  512;  Syme's  method,  509;  Syme's 
method,  fallacies  of,  511;  Syme's 
method,  results  of,  512;.  Wyeth's 
method,  511. 

Ankle  joint,  arthrectomy  of,  Bruns- 
425;  Busch's  non-subperiosteal  excision 
of,  413;  excision  of,  411;  landmarks  for 
excision  of,  412;  Langenbeck's  subperi- 
osteal excision  of,  412;  results  of  ex- 
cision of,  414;  treatment  after  excision 
of,  414;   Vogt's  excision  of,  413. 

Annandale's  operation  for  removal  of 
nasal  growths,  657. 

Anterior  dental  nerve,  division  of,  278. 

Anterior  tibial  artery,  anatomical  points 
of,  150;  ligature  of,  150;  linear  guide  to, 
151;  muscular  guide  to,  151. 

Antipyrine  solution  for  control  of  hsemor- 
rhage,  241. 

Antiseptic,  dressings,  107 ;  and  aseptic 
methods,  50;  gauze,  improvised,  112; 
method,  94;  technique  in  gunshot 
wounds  of  the  cranium,  266;  varnish. 
Whitehead's,  639. 

Antrum,  mastoid,  opening  of,  262. 

Aorta,  abdominal,  compression  of,  540; 
digital,  540 ;  with  Davy's  lever,  541 ; 
with  Esmarch's  tourniquet,  541 ;  with 
Lister's  tourniquet,  541;  with  Pan- 
coast's  tourniquet,  541. 

Aorta,  abdominal,  contiguous  anatomy 
of,  130;  ligature  of,  130;  ligature  of, 
Cooper's  method,  130. 

Aortic  tissue  ligatures,  93. 

Apparel  of  surgeon  and  assistants,  115. 

Aqua  ammonia  for  cleansing  hands,  114. 

Arches,  palmar,  ligature  of,  190;  guide  to 
linear,  190;  precautions  in  ligature  of, 
190;  relations  of,  190. 

Aristol,  110. 

Arm,  amputation,  483;  antero-posterior- 
fiap  method,  484;  circular-flap  method, 
483;  irregular  double-flap  method,  484; 
irregular  double-flap  method,  remarks 
on,  484;  large  anterior  and  small  pos- 
terior skin-flap  method,  485;  musculo- 
cutaneous flaps  in  Langenbeck's,  484; 
Teale's  method,  485. 

Arm,    amputation    at    surgical    neck    of 


humerus,  485 ;  anatomical  points  for, 
485;  oval  method,  Guthrie's,  486;  re- 
marks on,  486;  results  of,  486;  single 
external-flap    method,   Farabeuf's,    486. 

Armamentarium,  variety  and  extent  of, 
45. 

Arterial  infusion,  223;  selection  of  vessel 
for,  223. 

Arterial  pressure  in  shock,  122;  tension 
in  shock,  122. 

Arteries,  accompanied  by  a  single  vein, 
125;  accompanied  by  venae  comites, 
125;  color  of,  126;  common  iliacs,  rela- 
tions of,  132;  guides  to,  125;  instru- 
ments required  to  ligature,  in  continu- 
ity, 129;  ligature  of,  general  considera- 
tions of,  125;  ligature  of,  in  continuity, 
125;  pulsation  of,  126;  relation  of,  to 
veins,  126;  special  operations  on,  202. 

Arteriorrhaphy,  211;  Bangle's  method, 
214;  Murphy's  method,  213;  Salo- 
mon's method,  214;  suture  material 
for,  213;  when  the  wound  exceeds  one- 
half  the  circumference  of  the  vessel, 
213;   remarks  on,  214. 

Artei'io-venous  aneurism,  extirpation  of, 
202. 

Artery,  digital  compression  of  femoral, 
540;  iliac,  internal,  relations  of,  135; 
middle  meningeal,  237;  scapular,  possi- 
ble origin  of,  173. 

Artery,  ligature  of,  anterior  tibial,  150; 
axillary,  178;  brachial,  180;  common 
carotid,  191 ;  common  carotid,  both, 
193;  common  carotid,  temporary,  194; 
common  iliac,  131;  deep  epigastric, 
141;  deep  circumflex  iliac,  142;  dorsalis 
pedis,  153;  dorsalis  penis,  138;  external 
carotid,  194;  external  circumflex,  148; 
external  iliac,  138;  facial,  200;  femoral, 
142;  femoral,  common,  143;  femoral, 
deep  (profunda),  148;  femoral,  super- 
ficial, 145;  gluteal,  136;  inferior  thy- 
roid, 177;  innominate,  158;  internal 
carotid,  195;  internal  iliac,  135;  inter- 
nal mammary,  177;  internal  pudic, 
137;  lingual,  197;  middle  meningeal, 
214;  occiiiital,  201;  peroneal,  155;  pop- 
liteal, 149;  posterior  tibial,  153;  pro- 
cedure for,  126;  radial,  185;  sciatic, 
136;  subclavian,  168;  superior  thyroid, 
197;  temporal,  201;  ulna,  188;  verte- 
bral, 174. 

Artery  compressor.  Gross's,  78. 

Arthrectomy,  424;  of  ankle  joint,  Brun's, 
425 ;  results  of,  424. 

Arthi'otomy  at  hip,  for  dislocation,  431; 
incisions  for,  431;  instruments  for,  431; 
results  of,  431. 

Arthrotomy  for  irreducible  dislocation  of 
humerus,  391 ;  with  fracture,  392 ;  with- 
out fracture,  392;  remarks  on,  393;  re- 
sults of,  393;   treatment  after,  393. 

Artificial  hjemostatics,  65;  heat  after  an- 
Eesthesia,  21;  larynx,  708;  respiration, 
119. 


INDEX. 


Ai3eptic  and  antiseptic  solutions,  59. 

Aseptic  dressing,  107;  iiictliod,  50,  !)4 ; 
gauze,  improvised,  112;  gauze  pads,  03; 
towels  and  sheets^  57. 

Asphyxia,  after-effects  of,  20;  care  of  pa- 
tients after,  21 ;  circulatory  depression 
during,  17;  stertor  during,  17. 

Asjjiration  of  heart,  123. 

Aspirator,  trachea,  684. 

Assistants,  disposition  of,  at  operation, 
93;  number  of,  necessary  for  an  opera- 
tion, 93;  one  necessary  as  an  auffisthet- 
ist,  93 ;  preparation  of,  for  an  opera- 
tion, 113. 

Astragalo-scaphoid  joint,  excision  of,  for 
relief  of  talipes,  Ogston's,  449. 

Astragalus,  amputation  through,  Han- 
cock's, 508 ;  enucleation  for  clubfoot, 
Lund's,  449 ;  enucleation  for  clubfoot, 
results,  449;  excision  of,  410;  excision 
of,  by  oval  incision,  410;  excision  of, 
by  double  incision,  411;  linear  osteot- 
omy of  neck  of,  for  talipes  equinus-va- 
rus,  448;  removal  of,  for  relief  of  ta- 
lipes, Vogt's,  449. 

Auricularis  magnus  nerve,  operation  on, 
320. 

Auriculo-temporal  nerve,  exposure  of, 
289 ;  guide  to,  289. 

Axillary  artery,  anatomical  points  of  first 
portion,  178;  guides  to,  first  portion, 
178;  guides  to  third  portion,  179;  liga- 
ture of,  178;  relations  of  first  portion, 
178;  relations  of  third  portion,  180; 
three  points  for  ligature,  178. 

Axillary  vein,  results  of  ligature  of,  215. 

Baker's  operation  for  removal  of  tongue 
with  ecraseur,   641. 

Ballance  and  Edmunds  stay  knot,  84; 
in  ligature  of  the  innominate,   162. 

Balsam  of  Peru  after  operation,  118. 

Bandage,  Esmarch's  elastic,  69;  Martin's, 
70. 

Bandages,  108;  elastic  in  shock,  119;  in- 
elastic, as  hfemostats,  68. 

Bandaging  to  control  bleeding,  96. 

Bardenheuer's  method  of  ligature  of  the 
innominate,  161. 

Barker's  excision  of  hip  joint,  428;  pegs 
in  excision  of  knee  joint,  422. 

Barton's  cuneiform  osteotomy  for  anchy- 
losis of  knee  joint,  441 ;  operation  for 
bony  anchylosis  of  knee  joint,  558. 

Batteries,  storage,  for  galvano-cautery,  81. 

Battery,  electric,  during  operation,  119. 

Bauden's  amputation  at  knee  joint,  526 ; 
modification  of  Lisfranc's  tarso-meta- 
tarsal  amputation,  504;  oblique  incision 
for  excision  of  upper  end  of  humerus, 
385. 

Baum's  opei'ation  for  exposing  facial 
nerve,  307;  comments  on,  309;  results 
of,  310. 

Bellocq's  cannula  for  plugging  posterior 
uares,  650. 


Bennett's  inhaler,  28,  33. 

Bergcr's  amputation  above  the  shoulder 
joint,  492. 

Beta  eucain,  43. 

]}eta-naphthol,  61  ;   for  instruments,  52. 

Biceps  flexor  cubiti,  tenotomy  of,  332. 

Biceps  ilexor  cruris,  tenotomy  of,  336. 

Bichloride  gauze,  111;  objections  to, 
113. 

Bichloride  of  mercury,  instability  of,  113; 
tablets  of,  113. 

Bier's  osteoplastic  amputation  of  leg, 
530. 

Billroth's  method  of  removal  of  tongue, 
642 ;   method  of  tendon  suturing,  340. 

Binders,   108. 

Biniodide  of  mercury,  solutions  of,  60. 

Bird's  cuneiform  osteotomy  for  relief  of 
talipes,  449 ;  excision  of  knee  joint 
through  transverse  incision,  419. 

Birthmark,  223. 

Birthmark,  treatment  of,  by  electrolysis, 
224;  by  freezing  and  incisions.  Squire's, 
223 ;  by  heated  needles,  224 ;  by  in- 
jection, 224;  by  Paquelin's  cautery, 
224. 

Blasius's  method  of  cheiloplasty  of  lower 
lip,  606. 

Bleaching  powder  for  cleansing  the  hands, 
114. 

Bleeding   from    operation  wounds,   96. 

Blood,  during  shock,  120 ;  examination 
after  operation,  118;  in  operation 
wound,  97;   shock  due  to  loss  of,   121. 

Blood-clot,  organization  of,  in  osteo- 
plasty, 450. 

Bloodless  stretching  of  great  sciatic 
nerve,    326. 

Blunt  dissection,  49. 

Boeckel's  operation  for  removal  of  nasal 
growths,  657. 

Boiled  water,  62. 

Bone,  caries  of,  356;  chips  in  osteoplasty, 
450;  chips,  preparation  of,  450;  exci- 
sion of,  361 ;  flap  in  craniotomy,  251 ; 
fracture  of  hyoid,  724;  functions  of, 
356;  necrosis  of,  356;  subperiosteal, 
removal  of,  361 ;  transplantation  of, 
450;  transplantation  of,  en  masse,  450; 
treatment  of,  in  amputations,  452. 

Bone-cutting  forceps,  Liston's,  465. 

Bone-forceps,  in  dislocation  and  frac- 
ture  of  the   humerus,  392. 

Bone-holding  forceps  for  excision  of  bone, 
364. 

Bones,  fixation  of,  after  excision  of  knee 
joint,  422  ;   long,  distortion  of,  559. 

Bones,  metacarpal,  amjnitation  of  foTir, 
with  fingers,  476;  of  inner  three,  476; 
of  last  four,  475;  of  last  two,  476; 
through,  475. 

Bones,  metatarsal,  amputation  through, 
500. 

Bones,  of  the  face,  excision  of,  365:  of  the 
leg,  excision  of,  416;  operations  on, 
35(). 


VI 


INDEX. 


Bony  defects,  Neuber's  method  of  healing 
by  canalization,  358;  Schede"s  method 
of  healing,  358. 

Bony  guide  to  artery,  125;  to  external 
carotid  artery,  195;  to  inferior  thyroid 
artery,  178;  to  internal  carotid  artery, 
196 ;  to  temporal  artery,  201 ;  to  lingual 
artery,  198;  to  subclavian  artery,  sec- 
ond and  third  portions,  172;  to  verte- 
bral artery,  175. 

Bony  guides,  to  facial  nerve,  307 ;  to  sub- 
clavian artery,  168. 

Bony  landmarks  of  the  skull,  245. 

Boric  acid,  saturated  solution  of,  61. 

Bougie,  oesophageal,  664;  conical, 
Knott's,  674. 

Bow  legs,  osteotomy  for,  445. 

Brain,  abscess,  results  after  operation  on, 
260 ;  exploration  of,  for  pus,  258 ;  ex- 
ploration of,  for  tumor,  253;  foreign 
bodies  found  within,  after  gunshot 
wounds,  266;  injury,  shock  due  to, 
120;  penetration  of,  with  probe,  267; 
tumor,  craniotomy  for,  245 ;  tumor, 
results  of  operation  for,  255;  tumor, 
treatment  of,  253. 

Brachial  artery,  anatomical  points  of, 
180;  guides  to,  180;  high  bifurcation 
of,  183;  ligature  of,  180,  182;  points 
for  ligature  of,   181;    relations  of,   ISO. 

Brachial  plexus,  operation  on  branches  of, 
321. 

Bradford's  linear  osteotomy  of  neck  of  as- 
tragalus for  talipes  equino  varus,  448. 

Branchial  cysts,  733. 

Brandy,  119;   with  ansesthetics,  35. 

Brisment  force  for  anchylosed  joints,  558; 
for  anchylosed  knee  joint,  558;  for  an- 
chylosed knee  joint,  results  of,  559;  for 
anchylosed  knee  joint,  treatment  after, 
559. 

Broca's  convolution,  250. 

Bronchitis  after  ansesthesia,  21. 

Bi'onchotomy,  681;  anatomical  points  for, 
681;  anaesthetic  for,  682;  general  com- 
ments on,  690 ;  instruments  for,  683 ;  re- 
sults of,  692 ;  treatment  after,  685, 
692 ;   use  of  thermo-cautery  in,  690. 

Bronchus,  foreign  body  in,  699. 

Brown's  (Tilden)  clamp  for  conti'olling 
htemorrhage  in  amputation  at  hip 
joint,  546. 

Bruised  tissue,  drainage   of,  105. 

Bruns's"  amputation  of  foot,  515;  arthree- 
tomy  of  ankle  joint,  425;  method  of 
cheiloplasty  of  lower  lip,  608;  method 
of  cheiloplasty  of  upper  lip,  612;  meth- 
od of  flap  transfer  in  plastic  surgery, 
573. 

Bryant's,  J.  D.,  amputation  of  leg  with 
periosteal  flap,  516. 

Buccal  nerve,  exposure  of,  290;  operations 
on,  290;  results  of  operations  on,  290. 

Buccal  route  to  inferior  dental  nerve,  285. 

Buchanan's  method  of  cheiloplasty  of 
lower  lip,  609, 


Buckhardt's  method  of  opening  retro- 
phalangeal  abscess,  727. 

Buck's  intero-lateral-flap  method  of  chei- 
loplasty of  upper  lip,  612;  method  of 
cheiloplasty  of  lower  lip,  609  ;  method  of 
stomatoplasty,  615;  pin,  76;  pin  car- 
rier, 103 ;  semicircular  vertical-flap 
method  of  cheiloplasty  for  entire  loss  of 
upper  lip,  613. 

Bullet,  approach  of,  through  counter 
opening  in  cranium,  author's  method, 
269 ;  location  of,  after  gunshot  wounds 
of  cranium,  267 ;  removal  of,  after  gun- 
shot wounds  of  cranium,  268. 

Bunion,  operations  for,  447;  treatment 
of,  and  remarks  on,  568. 

Buried  suture,  103. 

Burow's  method  of  flap  transfer  in  plastic 
surgery,  573. 

Burrell's  method  of  ligature  of  the  in- 
nominate, with  resection  of  the  sterno- 
clavicular articulation  and  upper  end 
of  sternum,  160;  operation  for  habitual 
dislocation  of  humerus,  393. 

Bursae,  352 ;  mucous,  353. 

Bursitis,  postolecranon,  treatment  of, 
354;   prepatellar,  treatment  of,  353. 

Busch's  non-subperiosteal  excision  of 
ankle  joint,  413. 

Button  suture,  103. 

Cachexia  thyreopriva,  722. 

Caffein  citrate,  119. 

Calcaneum,  attachment  of  tendo-Aehil- 
lis,  409;  excision  of,  409;  gouging  of, 
409. 

Calcium  chlorid  in  cholfemia,  67 ;  in 
haemophilia,  67. 

Canalization,  drainage  by,  107. 

Capillaries,  operations  on,  215-223. 

Cannula,  Bellocq's,  650. 

Carbolic  acid,  60 ;  injection  of,  in  goitre, 
Senn,  722;  in  preparation  of  field  of 
operation,  95;  solutions,  59;  solutions 
for  instruments,  52;  with  oleaginous 
substances,  60. 

Carbonate  of  soda,  for  cleansing  the 
hands,  114;  solutions  of,  for  instru- 
ments, 62. 

Carden's  amputation  of  thigh  through 
condyles,  528 ;  results  of,  528. 

Cardiac  action  during  shock,  120, 

Caries  of  bones,  356. 

Carious  bone,  gouging  of,  356;  comments 
on  gouging  of,  356. 

Carnochan-Chavasse  operation  on  second 
division  of  trifacial  nerve,  283;  pre- 
cautions in,   283. 

Carnot's  solution,  66. 

Carotid  artery,  common,  anatomical 
points  of,  191 ;  common,  ligature  of, 
190;  external,  anatomical  points  of, 
194;  external,  excision  of,  Dawbarn, 
209;  external,  guides  to,  195;  external, 
ligature  of,  194;  external,  relations  of, 
194;    internal,    anatomical    points    of, 


INDEX. 


vn 


190;  internal,  guides  to,  lOG;  internal, 
injury  of,  in  excision  of  llie  tonsil, 
034;  internal,  ligature  of,  190;  inter- 
nal, relations  of,  190. 

Carpo-metacarpal  articulation,  amputa- 
tion at,  of  thumb,  little,  and  index  fin- 
gers, 473. 

Carrier,   pin,   Buck's,    103;    Post's,   103. 

Cartilage,  thyroid,  OSl. 

Catgut,  cJiromacized,  93;  chromacized,  in 
radical  cure  of  aneurism,  207 ;  drain- 
age,  100. 

Catgut  ligatures,  81,  80;  characteristics 
of,  87  ;  chromacized,  90;  cumolized,  91  ; 
length  of,  87 ;  preparation  of,  87 ; 
sterilization  of,  87;  tensile  strength  of, 
87 ;  varieties  of,  87. 

Catgut,  preparation  of,  at  Bellevue  Hos- 
pital, 87;  at  Jefi'erson  Hospital,  92;  at 
Johns  Hopkins  Hospital,  92;  at  New 
York  Hospital,  92;  at  Saint  Luke's 
Hospital,  92. 

Catgut  sutures,  97. 

Catlin  in  amputating,  463. 

Caustic  soda  in  preparation  of  dressings, 
113. 

Cautery  as  an  haemostatic,  79;  for  con- 
trol of  hsemorrhage,  79,  241 ;  Paquelin, 
in  treatment  of  birthmark,  224. 

Cavity,  filling  of,  with  bone  chips  in  os- 
teoplasty, 4.50;  preparation  of,  in  os- 
teoplasty, 450. 

Cellulitis,  danger  of,  in  operations  on 
thyroid,  722. 

Celluloid  plate,  use  of,  after  craniotomy 
for  epilepsy,  256. 

Celluloid  thread  suture,  98. 

Celsus's  method  of  cheiloplasty  of  lower 
lip,  607;  single  circular  incision  method 
of  amputation  of  thigh,  536. 

Cerebellar  abscess,  260. 

Cerebellar  tumor,  craniotomy  for,  255. 

Cerebral  abscess,  258;  operation  for,  259; 
operation  for,  precautions  in,  260. 

Cerebral  tumor,  craniotomy  for,  251. 

Cervical  nerves,  operations  on  branches 
of,  320;  excision  of  posterior  branches 
of  first  three,  320;  resection  of  jDOste- 
rior  divisions  of,  for  spasmodic  wry- 
neck, 562. 

Cervical  oesophagotomy,  668 ;  fallacies  of, 
668 ;  remarks  on,  609 ;  results  of,  670 ; 
treatment  after,  670. 

Chain  saw,  for  excision  of  bone,  364. 

Chalot's  operation  for  nasal  growths, 
656. 

Champagne,  119. 

Chassaignac's  operation  for  nasal  and 
naso-pharyngeal  polypi,  654. 

Chavasse's  operation  on  tlie  second  por- 
tion of  trifacial  nerve,  283. 

Cheek,  deformities  of,  616. 

Cheever's  method  of  pharyngotomy,  645 ; 
remarks  on,  645;  operation  for  nasal 
growths,  659. 

Cheiloplasty,  605, 


Cheiloplasty  of  lower  lip,  605;  Blasius's 
method,  006;  Bruns's  method,  608; 
liuck's  metliod,  609 ;  Celsus's  method, 
007;  Dowd's  method,  611;  Kstlunder's 
method,  607;  (iranfs  method,  006; 
horizontal  incision  metliod,  606;  Lan- 
genbeck's  circular  method,  608;  Lan- 
genbeek's  chin-flap  method,  009;  Mal- 
gaigne's  method,  610;  Sedillot's  meth- 
od, 611;  fSyme-Buchanan  method,  609; 
Syme's  method,  009;  "V  "-incision 
method,  605. 

Cheiloplasty  of  upper  lip,  612;  Bruns's 
method,  612;  Buck's  method,  612; 
Buck's  semicircular  vertical-flap  meth- 
od, 613;  Uiefienbach's  curved  flap 
method,  614;  Uiellenbach's  "  S  "- 
shaped  flap  method,  614;  for  entire 
loss,  612;  Ledran-JNlackenzie  method, 
615 ;  Sedillot's  vertical-flap  method, 
613;   Szymanowski's  method,  614. 

Cheyne's  method  of  drainage  of  the  lat- 
eral ventricles,  229. 

Chiene's  method  of  locating  the  Fissure 
of  Rolando,  247 ;  method  of  opening 
retropharyngeal  abscess,  726;  operation 
of  osteo-arthrotomy  for  genu  valgum, 
444. 

Chicken  bones,  drainage  with,   106. 

Chisel,  for  osteotomy,  435;  Hartley's, 
298 ;  Pyle's,  298. 

Chloi'ide  of  lime  for  cleansing  the  hands, 
114. 

Chloride  of  zinc,  solutions  of,  60. 

Chloroform,  28;  administration  of,  29; 
before  ether,  34;  dangers  of,  17;  in- 
halers, 30 ;  mixtures  of,  before  ether,  34, 

Chloroform  anfesthesia,  28 ;  cases  suited 
for,  29;  cause  of  death  during,  28, 
29;  death  rate  of,  22;  in  craniotomy, 
238. 

CholEemia,  action  of  calcium  chlorid  in, 
67. 

Chopart's  amputation  at  mediotarsal 
joint,  504. 

Chromacized  catgut,  90;  sutures,  97, 

Chronic  hydrocephalus,  227;  drainage 
agents  in,  228. 

Chronic  thecitis,   352. 

Cicatricial  contraction,  Croft's  operation 
for,  578. 

Cicatrix,  position  of,  after  amputation, 
451. 

Cricoid  growth,  treatment  of,  by  division 
and  ligature,  226. 

Circular  craniotomy  for  fracture  of  skull, 
im])ortant  considerations  of,  236:  for 
fracture  of  skull,  repair  of  cranial 
opening  after,  235;  for  fracture  of  skull, 
results  of,  238:  removal  of  button  in, 
234 :  utilization  of  rongeur  and  gouge 
in,  235, 

Circumclusion,  for  arrest  of  haemorrhage, 
76. 

Cireumfle.x  artery,  external,  ligature  of, 
148. 


VUl 


INDEX. 


Circumflex  iliac  artery,  deep  ligature  of, 
142. 

Circumflex  nerve,  arm,  operation  on, 
323. 

Clamp,  for  correction  of  deviation  of  sep- 
tum nasi,  661;  Langenbeck's,  69;  Til- 
den  Brown's,  for  control  of  hismor- 
rhage  in  amputation  at  the  hip  joint, 
546. 

Clark's  method  of  preparing  catgut,  91. 

Clavicle,  anatomical  relations  of,  379 ;  ex- 
cision of,  379 ;  morbid  processes  of,  379 ; 
operation  for  malignant  growth  of, 
380. 

Cleanliness  of  a  wound,  drainage  as  a 
factor  in,  104. 

Cleveland's  operating  table,  54. 

Clover's  inhaler,  26. 

Coaptation  and  relaxation  suture,  104. 

Coaptation,  retentive,  of  wound  surfaces, 
96. 

Cocain  as  a  local  ansesthetic,  37 ; 
for  arrest  of  haemorrhage  from  brain, 
241;  in  tenotomy,  331;  in  the  pre- 
vention of  shock,  121;  sterilization 
of,  41. 

Coccyx,  excision  of.  432. 

Coffee,  119;  in  shock,  121. 

Coleman's  method  of  controlling  hsemor- 
rhage  in  typhoid  fever,  66. 

Collapse,  120,  122. 

Colley's  method  of  uranoplasty,  626. 

Collodion,  101;  styptic,  68. 

Colly's  cuneiform  osteotomy  of  tarsus  for 
talipes  equino-varus,  447. 

Combined  dressing,  108. 

Common  carotid  arteries,  ligature  of  both, 
193. 

Common  carotid  artery,  anatomical 
points  of,  191;  guides  to,  191;  ligatui'e 
of,  190;  points  for  ligature  of,  192;  re- 
lations of,  191;  temporary  ligature  of, 
194. 

Common  iliac  arteries,  relations  of,   132. 

Compensative  appliances  after  amputa- 
tion, 451. 

Composition  of  iodoform  gauze.  111. 

Compresses  as  haemostatics,  70. 

Considerations,  important,  in  treatment 
of  operation  wound,  96. 

Condyles,  amputation  of  thigh  through, 
528;  Carden's  method,  528;  Carden's 
method,  results,  528;  Farabeufs  modi- 
fication of  Carden's  method,  529; 
Gritti's  method,  529;  Lister's  modifi- 
cation of  Carden's  method,  528;  re- 
sults of  Stokes's  and  Gritti's  method, 
530;  Sabanejelf's  osteoplastic  method, 
532;  Stokes's  modification  of  Gritti's 
method,  .529. 

Cone,  cloth  and  paper,  24. 

Congenital  deformities,  558. 

Congenital  displacement  of  hip,  Hoffa's 
opei^ation,  439;  Lorenz's  operation, 
440;  results  of  Hoft'a's  operation,  440; 
results    of     Lorenz's     operation,     440; 


treatment  after  Hoff'a's  operation, 
439. 

Contiguous  anatomical  guide  to  an  ar- 
tery,  125. 

Contiguous  anatomy  of  abdominal  aorta, 
130,  131;  of  axillary  artery,  first  por- 
tion, 178;  of  axillary  artery,  third  por- 
tion, 180;  of  brachial  artery,  180;  of 
common  carotid  artery,  191;  common 
iliac  artery,  132;  of  external  carotid 
artery,  194;  external  iliac  artery,  139; 
of  femoral  artery,  142;  of  inferior  thy- 
roid artery,  177;  innominate  artery, 
158;  of  internal  carotid  artery,  196; 
of  internal  iliac  artery,  135 ;  of  internal 
pudic  artery,  138;  of  palmar  arches, 
190;  of  popliteal  artery,  149;  of  radial 
artery,  185;  of  sciatic  artery,  137;  of 
subclavian  artery,  first  portion,  left 
side,  169;  subclavian  artery,  first  por- 
tion, right  side,  170;  subclavian  ar- 
tery, second  portion,  174;  subclavian 
artery,  third  portion,  171;  of  ulna  ar- 
tei'y,  188;  of  vertebral  artery,  174. 

Continuitj^  ligature  of  arteries  in,  125. 

Continuous  suture^  102. 

Cooper's  method  of  ligaturing  abdom- 
inal aorta,  130;  of  ligaturing  the  in- 
nominate, 162. 

Cornu,  posterior    (brain),  249. 

Corrosive  sublimate  solutions,  59. 

Cotting's  operation  for  ingrown  toe-nail, 
568. 

Cotton  batting  dressing,  108. 

Cotton  gloves,  115. 

Cotton,  medicated,  108. 

Cranio-cerebral  topography,  245. 

Craniotomy,   circular,  231. 

Craniotomy,  for  fracture  of  the  skull, 
231;  for  brain  tumor,  245;  for  brain 
tumor,  precautions,  254;  for  brain  tu- 
mor, results,  255;  for  cerebral  tumor, 
251;  for  cerebellar  tumor,  255;  for 
cerebellar  tumor,  precautions,  256; 
for  cerebellar  tumor,  results,  256; 
for  epilepsy,  256;  for  epilepsy,  introduc- 
tion of  foreign  substances  after,  256 ; 
for  epilepsy,  remarks  on,  257 ;  for  epi- 
lepsy, results,  257;  for  evacuation  of 
pus,  257 ;  for  general  paralysis  of  the 
insane,  261;  foi;  gunshot  wounds,  266; 
for  gunshot  wounds,  after  treatment, 
270;  for  gunshot  wounds,  precautions 
in,  270 ;  for  gunshot  wounds,  results, 
270;  for  meningeal  hjemorrhage,  238; 
for  meningeal  hsemorrhage,  precau- 
tions, 239 ;  for  meningeal  hsemorrhage, 
results.  239 ;  for  microcephalus,  linear, 
241 ;  for  thrombosis  of  lateral  sinus 
and  jugular  vein,  260 ;  for  thrombosis 
of  lateral  sinus  and  jugular  vein,  pre- 
cautions, 261 ;  for  thrombosis  of  lateral 
sinus  and  jugular  vein,  results,  261 ; 
varieties  of,  231. 

Cranium,  gunshot  wounds  of,  266;  tre- 
phining of,  23X. 


INDEX. 


IX 


Crede's  operation  on  trifacial  nerve  at 
foramen  ovale,  293. 

Cricoid  cartilage,  082. 

C'rico-laryngotoniy,  087. 

Crico-thyroid  space,  G82. 

Cricotomy,  685. 

Crile  on  action  of  adrenalin,  07. 

Crile's  hot-water  mattress,  55;  rubber 
suit  for  shock,  122 ;  treatment  of  shock, 
121;  views  on  shock,  120. 

Croffs  operation  for  cicatricial  contrac- 
tion, 578;    remarks  on,   580. 

Cruial  nerve,  anterior,  operation  on,  327. 

Cumolized   catgut,  91. 

Cuneiform  osteotomy,  433. 

Curvature  of  spine,  500 ;  plaster-of-Paris 
jacket  for,  Sayre,  500. 

Curtis's  method  of  ligaturing  the  innomi- 
nate, 104;  placing  of  ligature  in,  106; 
remarks  on,  107. 

Cushing's  method  of  intracranial  neurec- 
tomy of  trifacial  nerve,  303;  remarks 
on,  305;  results  of,  300. 

Cushing's  operation  for  facial  paralysis 
of  extra  cerebral  origin,  310;  remarks 
on,  310. 

Cushion  of  oakum  after  operation,  118. 

Cushion,   rubber,  surgical,  54. 

Cutaneous  amputation  flaps,  452. 

Cutting  tendency  of  silkworm  gut,  98. 

Cyanosis  during  shock,  122. 

Cystic  tumor  of  brain,  treatment  of,  254. 

Cysts,  branchial,  733. 

Czerny's  method  of  pharyngotomy,  646. 

Davidson's  sj^ringe,  119. 

Davies-Colly,  cuneiform  osteotomy  of, 
tarsus  for  talipes  equino-varus,  447. 

Davies-Colly  method  of  uranoplasty, 
020 ;   remarks  on,  626. 

Davy's  lever,  73 ;  for  compressing  ab- 
dominal aorta,  541. 

Dawbarn's  excision  of  externus  carotid, 
209;  method  of  saline  transfusion,  221; 
removal  of  external  carotid  arteries, 
194. 

Dead  spaces,  in  operation  wound,  97; 
management  of,  101,  104. 

Death,  cause  of,  after  excision  of  lower 
jaw,  377;  after  intracranial  neurec- 
tomy of  trifacial  nerve,  301 ;  in  ampu- 
tation at  hip  joint,  540. 

Death,  due  to  air  in  veins,  122;  following 
rupture  of  third  perforating  branch  of 
the  profimda  artery,  148 ;  from  lateral 
ligature  of  the  internal  jugular  vein 
(Braun),  215. 

Death-rate  after  linear  craniotomy,  245 ; 
for  removal  of  brain  tumor,  255. 

Deaths    from   auipsthetics,  22,   43. 

Dec's  operation  for  webbed  fingers,  504. 

Decalcified  tubes,  Neuber's,  for  drainage, 
106. 

Deep  palmar  arch,  incision  for,  191. 

Deep  sutures,  98. 

Deformities,    558;    dependent    upon    per- 


verse muscular  action,  501 ;  due  to 
fusion,  563;  of  cheek,  616;  of  moutli, 
015;  of  nose,  592;  of  nose,  operations 
for,  593;  of  nose,  comments  on,  593; 
of  nose,  injection  of  paradin  for,  593; 
upper  lip,  612. 

Deformity  of  nasal  septum,  661. 

Deguise's  operation  for  salivary  fistula, 
033. 

Deltoid,  myotomy  of,  348. 

Denhard's  mouth  gag,  285. 

Dental  nerve,  anterior,  division  of,  278. 

Dental  nerve,  inferior,  284;  comments  on 
operation  on,  280 ;  exposure  of,  in  den- 
tal canal,  288;  external  or  facial  route 
to,  280;  Horsley's  incision  for,  287;  in- 
ternal or  buccal  route  to,  285;  Keen's 
incision  for,  287;  Kiihn's  incision  for, 
287 ;  Linhart's  incision  for,  287 ; 
Liicke's  incision  for,  287 ;  operation  on, 
285;  precautions  for  operation  on,  280, 
288;  situations  for  exposure  of,  285. 

Desault's  operation  for  salivary  fistula. 
032. 

Desprez's  operation  for  removal  of  nasal 
and  naso-pharyngeal  polypi,  653. 

Diagram  of  arrangements  for  operation, 
115. 

Diday's  operation  for  webbed  fingers, 
564;  objections  to,  505. 

Dieffenbach-i^'ergusson  method  of  urano- 
plasty, 625;  remarks  on,  625. 

Dieff'enbach's  circular-flap  method  of  am- 
putation at  hip,  552;  method  of  flap 
transfer  in  plastic  surgery,  572 ;  opera- 
tion for  single  harelip,  602 ;  operation 
of  rhinoplasty,  584;  pyriform  flap  in 
rhinoplasty,  589 ;  "  S  ''-shaped  flap 
method  of  cheiloplasty,  614;  curved- 
flap  method  of  cheiloplasty,  614. 

Diet,  9. 

Digital  pressure  as  an  hfemostatic,  71. 

Digitalis,  119;   during  shock,  122. 

Director,  grooved,  47,  129. 

Disarticulation  at  ankle  joint,  509;  at 
carpo-metacarpal  joint  of  three  inner 
metacarpal  bones,  473;  at  elbow  joint, 
481;  at  hip  joint,  540;  at  knee  joint, 
523;  at  knee  joint,  results,  527;  at 
mediotarsal  joint,  504;  at  metacarpo- 
phalangeal articulations,  471;  at  me- 
tatarso-phalangeal  joint,  499;  at  pha- 
langeal articulations  of  hand,  409 ;  at 
shoulder  joint,  480;  at  tarso-metatar- 
sal  joints,  502;  at  wrist  joint,  477. 

Disarticulation  of  great  toe,  498;  of  last 
four  metacarpal  bones,  475 ;  of  little 
toe,  498:  of  phalanges  of  toes,  496:  of 
toes,  497:   subastragaloid,  of  foot,  506. 

Dislocation  at  liip,  arthrotomy  for,  431. 

Dislocation  of  humerus,  habitual,  opera- 
tion for,  393 :  habitual,  results  of  opera- 
tion for,  393;  irreducible,  arthrotomv 
for,  391. 

Displacement  of  ulnar  nerve,  324:  ^lac- 
Cormac's  method  of  treatment  of,  324, 


INDEX. 


Dissection,  blunt,  49. 

Divided  tissues,  uniting  of,  98. 

Dorsalis  pedis  artery,  ligature  of,  153; 
linear  guide  to,  153;  muscular  guide 
to,   153. 

Dorsalis  penis  artery,  ligature  of,  138. 

Douche,  temperature  of,  117. 

Douching  cut  surfaces,  116. 

Douching  ajiparatus,  108;  improvised, 
108. 

Dowd's  method  of  cheiloplasty  of  lower 
lip,  611;  remarks  on,  612. 

Downes's  thermic  angiotube,  79. 

Doyen's  method  of  intracranial  neurec- 
tomy of  trifacial  nerve,  302. 

Drainage,  104;  after  gunshot  ■\vounds  of 
the  cranium,  268,  270;  after  removal 
of  brain  tumor,  254;  agents  in  chronic 
hydrocephalus,  228;  anterior,  of  lateral 
ventricles  (Cheyne,  Southerland),  229; 
by  canalization,  107 ;  in  septic  cases, 
95 ;  means  of  securing,  105 ;  spinal  me- 
ningeal, 316;  with  catgut,  106;  with 
chicken  bones,  106;  with  horsehair, 
106;    with  silkworm  gut,   106. 

Drainage  tubes,  105;   removal  of,  106. 

Dressing,  combined,  108;  cotton  batting, 
108;  gauze,  110,  111,  112;  jute,  112; 
moss,  112;  muslin,  112;  open,  after  op- 
eration, 118;  peat,  112;  rubber  dam, 
108;  sawdust,  112;  wood  pulp,  112; 
wood  wool,  112. 

Dressings,  antiseptic,  107 ;  aseptic,  107 ; 
change  of,  after  operation,  118;  pro- 
tective, 107. 

Dry  stretching  of  nerves,  272. 

Dubrueil's  radial-flap  method  of  ampu- 
tation at  the  wrist  joint,  479. 

Duncan's  method  of  neuroplasty,  275. 

Dupuytren's  external  and  internal  flap, 
amputation  at   shoulder  joint,  488. 

Dupuytren's  contraction,  351;  Adams's 
operation  for,  351 ;  Goyraud's  opera- 
tion for,  351;  Hardie's  modification  of 
Goyraud's  operation  for,  351;  remarks 
on  operations  for,  352. 

Dura,  closure  of,  after  craniotomy,  314; 
exposure  of,  in  Hartley-Krause  opera- 
tion, 299;  opening  of,  in  laminectomy, 
313. 

Dural  flap  in  craniotomv  for  brain  tu- 
mor, 253. 

Duration  of  drainage,  105. 

Duval's  supramalleolar  amputation  of 
leg,  516. 

Ecraseur,  removal  of  tongue  with.  Ba- 
ker, 641. 

Edebohls's  method  of  preparing  ehroma- 
cized  catgut,  90;  operating  table, 
56. 

Edmunds's  stay  knot,  84;  in  ligature  of 
the  innominate,  162. 

Eiselsberg's  osteoplastic  amputation  of 
leg,  530. 

Elastic  bandage,  Esmarch's,  69. 


Elastic  bandages  in  shock,  119. 

Elbow  joint  amputation,  481;  anatomical 
points  for,  481;  anterior  single-flap 
method,  482;  circular  method,  482; 
comments  on,  483;  results  of,  483;  ellip- 
tical-fiap  methods,  481. 

Elbow  joint,  excision  of,  395 ;  Hliter's, 
395;  Langenbeck's,  396;  Liston's,  397; 
OUier's,  397;  Ollier's,  subperiosteal, 
396. 

Electric  battery,  during  operation,  119. 

Electro-cautery,  79. 

Electrolysis  in  treatment  of  birthmark, 
224. 

Emergencies,  special,  during  an  opera- 
tion, 120. 

Emphysema  after  wounds  of  neck,  724. 

Encapsulate  brain  tumor,  treatment  of, 
253. 

Encephalocele,  231. 

Endoscope  in  oesophageal  stricture,  674. 

Enemata,  high,  during  shock,  121 ;  of 
saline  fluid,  222. 

Engine,  surgical,  364. 

Enucleation  of  astragalus  for  clubfoot, 
Lund,  449;   results,  449. 

Enucleation  of  goitre,  Socin's,  718;  com- 
ments on,  718. 

Enucleation  resection  of  goitre,  Kocher's, 
717. 

Enteroclysis,  222;  during  shock,  121. 

Epidural  hsemorrhage,  238. 

Epigastric  artery,  deep,  ligature  of,  141 ; 
linear  guide  to,  141. 

Epilepsy,  craniotomy  for,  256;  operations 
for,  257. 

Epileptics,  operations  on,  6. 

Erasion  of  joint,  424. 

Erector  spinas,  myotomy  of,  338. 

Erysipelas,  6. 

Esmarch's  amputation  of  foot,  515;  band- 
age in  aneurism  of  the  extremities,  206, 
207;  elastic  bandage,  69;  inhaler,  30; 
operation  for  immobility  of  inferior 
maxilla,  377 ;  tourniquet  for  compres- 
sion of  abdominal  aorta,  541. 

Essential  oils,  62. 

Essential  requirements  relating  to  opera- 
tions, 9. 

Estlander's  method  of  cheiloplasty  of 
lower  lip,  607. 

Ether,  23;  amount  required  to  produce 
insensibility,  27 ;  as  a  local  ansesthetic, 
36;  contra-indications  to  use  of,  24; 
dangers  of,  17;  during  shock,  122;  hy- 
podermics of,  14;  inflammability  of, 
24;  in  preparation  of  field  of  operation, 
95;  manner  of  administering,  27;  with 
chloroform,  31. 

Ether  anaesthesia,  cerebral  excitement  in, 
24 ;   death-rate  in,  22 ;  stages  of,  28. 

Ether  inhalers,  24. 

Ethereal  solution  in  preparation  of  field 
of  operation,  95. 

Ethyl  chloride  as  a  general  anaesthetic, 
34;  as  a  local  anaesthetic,  36, 


INDEX. 


XI 


Ethyl  biomitlc  as  a  general  anajsthetic, 
34. 

Eiicain  hydiochlorate,  43. 

Eucalyptol,  6:^. 

Excision  of  ankle  joint,  411;  landmarks 
for,  412;  non-subperiosteal,  Buseh,  413; 
non-subperiosteal,  connnents  on,  414; 
results  of,  414;  subi^eriosteal,  Langcn- 
beck,  412;  Vogfs,  413;  treatment 
after,  414. 

Excision  of  astragalo-scaphoid  joint  for 
relief  of  talipes,  Ogston,  449. 

Excision  of  astragalus,  410;  anatomical 
points  for,  410;  by  double  incision, 
411;  by  oval  incision,  410;  results  of, 
411. 

Excision  of  bone,  361;  general  remarks 
on,  3G1;  incisions  for,  3(51;  instruments 
employed,  363;  in  young  persons,  362; 
time  for  operation  of,  362;  treatment 
of  wounds  after,  365;  usefulness  of 
member  after,  362. 

Excision  of  bones  of  face,  365. 

Excision  of  bones  of  forearm,  lower  ex- 
tremities of,  Bourgary,  400. 

Excision  of  bones  of  leg,  416;  precautions 
for,  416. 

Excision  of  calcaneuni,  409 ;  Farabeuf's 
incision  for,  410;  remarks  on,  410;  re- 
sults  of,   410. 

Excision  of  cervical  nerves,  posterior  di- 
visions of  first  three,  320;  results  of, 
320. 

Excision  of  clavicle,  379;  entire,  380;  in 
part,  381;  precautions  for,  381;  results 
of,  381. 

Excision  of  coccyx,  432. 

Excision  of  elbow  joint,  395;  anatomical 
points  for,  395  ;  Hunter's,  395 ;  Langen- 
beck's,  396;  Liston's,  397;  Ollier's, 
397;  subperiosteal,  396;  remarks  on, 
397;  results,  399;  treatment  after, 
398. 

Excision  of  external  carotid  artery.  Daw- 
barn's,  209;  comments  on,  210;  results, 
211. 

Excision  of  great  trochanter,  425. 

Excision  of  hip  joint,  425;  anatomical 
points  for,  425 ;  Barker's,  428 ;  conserv- 
ative subperiosteal  operation  of,  Lan- 
genbeck's,  427 ;  Earabeuf's,  428 ;  gen- 
eral remarks  on,  429;  methods  of,  426; 
radical  operation.  White's,  426;  results 
of,  430;  Sayre's,  429;  treatment  after, 
430. 

Excision  of  humerus,  384;  anatomical 
points  for,  384;  complete,  395;  head  of, 
388;  lower  extremity  of,  394;  partial, 
387;  results  of,  395;  shaft  of,  394;  sub- 
periosteal, of  head,  387;  treatment  after, 
395;  upper  end,  385;  upper  end,  Mac- 
Cormac's  posterior  incision  for,  380; 
upper  end,  oblique  incision  for,  385; 
upper  end,  through  Langenbeck's  ver- 
tical incision,  385;  upper  end,  through 
posterior  incision,  387. 


Excision  of  knee  joint,  41G;  anatomical 
points  for,  417;  by  transverse  incision, 
Bird's,  419;  lixalion  of  bones  after, 
422;  Kiinig's  method  of  fixing  bones 
after,  423;  non-subperiosteal,  Macken- 
zie, 418;  subperiosteal,  Langenbeck's, 
420;  subperiosteal,  Ollier's,  421;  re- 
nuirks  on,  421;  results  of,  423;  treat- 
ment after,  423. 

Excision  of  lower  jaw,  373;  alveolar  pro- 
cess of,  376;  anatomical  considerations 
for,  373;  central  portion  of,  374;  com- 
plete, 37G;  condyle  of,  378;  incisions 
for,  374;  lateral  portion  of,  375;  re- 
marks on,  374;  results  of,  377;  treat- 
ment after,  377. 

Excision  of  metacarpo-phalangeal  joints, 
407. 

Excision  of  metatarso-phalangeal  joint  of 
great  toe,  408. 

Excision  of  metatarso-phalangeal  joints, 
408. 

Excision  of  meningocele,  230,  318;  pre- 
cautions for,  230;  results  of,  231,  318. 

Excision  of  patella,  425;  precautions  in, 
425;   results  of^  425. 

Excision  of  phalangeal  joints  of,  407. 

Excision  of  radius,  399;  results  of,  400. 

Excision  of  scapula,  381;  acromion  pro- 
cess of,  382;  angles  of,  383;  body  of, 
382;  complete,  381;  complete,  Fergus- 
son's  method  of,  382;  glenoid  angle  of, 
3S3;  glenoid  angle  of,  MacCormac's, 
382;  glenoid  angle  of,  Pollock's,  382; 
remarks  on,  384;  results  of,  384; 
tSpence's,  382;  subperiosteal,  383;  treat- 
ment after,  384. 

Excision  of  shoulder  joint  from  behind, 
Kocher's,  390;   comments  on,  391. 

Excision  of  the  sternum,  379;  results  of, 
379. 

Excision  of  superior  maxillse,  simultane- 
ous, 372;   results,  373. 

Excision  of  the  sympathetic  for  exoph- 
thalmic goitre,  Jaboulay  and  Jonnes- 
co's,  721. 

Excision  of  tarso-metatarsal  joints,  408; 
remarks  on,  408. 

Excision  of  tongue,  methods  of,  635; 
"  V  "-shaped  incision  for,  635. 

Excision  of  tonsil,  633. 

Excision  of  ulna,   399;    results  of,  400. 

Excision  of  upper  jaw,  365 ;  below  floor 
of  orbit  with  median  incision,  369;  be- 
low infraorbital  foramen,  extra  buccal 
method,  371;  below  infraorbital  fora- 
men, intrabuccal  method.  371;  com- 
plete, 367;  complete,  anatomical  consid- 
erations for,  367:  complete  with  median 
incision.  368;  Fergusson's  incision  for, 
368;  Gensoul's  incision  for,  368;  Lan- 
genbeck's incision  for,  368;  lines  of  in- 
cision for,  367;  Liston's  incision  for, 
3(iS;  Lizar's  incision  for,  367:  par- 
tial, 371;  remarks  on.  365;  results  of, 
373;  subperiosteal,  370;  through  intra- 


xu 


INDEX. 


buccal  incisions,  370;  treatment  after, 
372;   Velpeau's  incision  for,  368. 

Excision  of  varicose  veins,  217. 

Excision  of  wrist  joint,  400;  comments 
on,  404;  complete  subperiosteal,  Lan- 
genbeck's,  402;  complete  subperiosteal. 
Lister's,  404;  complete  subperiosteal, 
Ollier's,  403;  important  considerations 
for,  400;  precautions  for,  405;  results 
of,  406;  treatment  after,  405. 

Excision,  treatment  of  spina  bifida  by, 
318. 

Excisions  of  lower  extremities,  407. 

Excisions  of  phalangeal  joints  of  tarsus, 
407. 

Excisions  of  upper  extremity,  384. 

Exophthalmic  goitre,  excision  of  sympa- 
thetic for,  Jaboulay  and  Jonnesco's, 
721. 

Exothyropexy,  Jaboulay's,  721. 

Exploration  of  brain  for  pus,  258;  for  tu- 
mor, 253. 

Extemporized  retractors,  129. 

Extensor,  brevis  pollicis,  tenotomy  of, 
331;  communis  digitorum,  tenotomy  of, 
331;  longus  digitorum,  tenotomy  of, 
335;  longus  pollicis,  tenotomy  of,  331; 
ossis  metacaipo  pollicis,  tenotomy  of, 
331;  proprius  hallucis,  tenotomy  of, 
335. 

External  carotid  artery,  ligature  of,  194. 

External  or  facial  route  to  inferior  dental 
nerve,  280. 

Extirpation  of  aneurism,  202;  of  the  ex- 
tremities, 206. 

Extrabuecal,  operation  on  buccal  nerve, 
Zuckerkandl's,  290;  route  to  lingual 
nerve,  289. 

Extract,  suprarenal,  as  an  hsemostatic,  66. 

Extraperitoneal  ligature  of  the  common 
iliac  artery,  133;  of  internal  iliac  ar- 
tery, 136. 

Fabrics,  textile,  sterilization  of,  112. 

Face,  excision  of  bones  of,  365. 

Facial  artery,  anatomical  points  of,  200; 
guides  to,  200;  ligature  of,  200. 

Facial  nerve,  307 ;  bony  guides  to,  307 ; 
exposure  of,  behind  pina,  Baum's,  307 ; 
stretching,  307;  stretching,  results  of, 
310. 

Facial  nerves  in  opening  the  mastoid  an- 
trum, 264. 

Facial  paralysis,  extracerebral  origin,  op- 
eration for,  Cushing's,  310;  remarks  on 
operation  for,  311. 

Facial  route  to  inferior  dental  nerve,  286. 

False  joint,  formation  of,  at  hip,  437. 

False  teeth,  removal  of,  before  anaesthe- 
sia, 11. 

Farabeuf's  amputation  of  leg  at  upper 
third,  521 ;  amputation  of  thigh,  long 
anterior  and  short  posterior  flap  meth- 
od, 537;  excision  of  hip  joint,  428;  for- 
ceps, 465 ;  incision  for  excision  of  os- 
calcis,  410;  internal  plantar-flap  meth- 


od of  amputation  for  great  or  little 
toes,  499;  modification  of  Garden's  am- 
putation of  thigh  through  condyles,  529. 

Fascia,  division  of,  127;  division  of  con- 
tracted, 352;  palmar,  350;  plantar,  349. 

Fasciae,  important,  349. 

Fasciatome,  349. 

Fauces  and  tonsil,  anatomical  points  of, 
644. 

Fauces,  pillar,  tumor  of,  and  of  tonsil,  re- 
moval ofj  644. 

Feeding  after  intubation  of  larynx, 
697. 

Femoral  artery,  anatomical  points  of,  142; 
digital  compression  of,  540;  ligature  of, 
142;  points  for  ligature  of,  143;  com- 
mon, ligature  of,  143 ;  common,  relations 
of,  142 ;  deep,  ligature  of,  148 ;  deep,  re- 
lation to  femur,  148;  superficial,  ana- 
tomical points  of,  145 ;  superficial,  liga- 
ture of,  145;  superficial,  relations  of, 
142. 

Femoral  vein,  results  of  ligature  of,  215. 

Femur,  division  of  neck  of,  Volkmann's, 
437 ;  diAdsion  of  neck  of,  with  osteotome, 
437;  intertrochanteric  osteotomy  of, 
Sayre's  modification  of  Barton's,  438 ; 
intertrochanteric  osteotomy  of,  Volk- 
mann's, 438;  neck  of,  subcutaneous  di- 
vision of,  Adams's,  436;  osteotomy  of 
shaft  of,  Gant's,  438;  treatment  of, 
after  osteotomy,  439. 

Fergusson's  incision  for  complete  excision 
of  upper  jaw,  368;  lion-jawed  forceps, 
465;  method  of  excision  of  scapula,  382; 
method  of  uranoplasty,  625,  626;  meth- 
od of  uranoplasty,  cases  suitable  for, 
628;  method  of  uranoplasty,  remarks 
on,  628;  method  of  uranoplasty,  treat- 
ment after,  628;  modification  of  Piro- 
goff"s  amputation  of  foot,  513;  opera- 
tion for  varicose  veins,  218. 

Fergusson- Webber's  incision  for  raising 
the  superior  maxilla,  660. 

Field  of  operation,  jjreparation  of,  94. 

Finger,  amputation  at  first  phalanx,  469; 
amputation  at  second  phalanx,  470;  in- 
dex, amputation  of,  at  carpo-metacar- 
pal  articulation,  473 ;  little,  amputation 
of,  at  carpo-metacarpal  articulation, 
473;  stalls,  rubber,  115;  supernumerary, 
563. 

Fingers,  amputations  of,  469;  webbed, 
563. 

Fissure,  intra-parietal,  249  ;  longitudinal, 
248  ;  parieto-occipital,  248 ;  precentral 
or  vertical  temporal,  249;  of  Rolando, 
246;  of  Rolando,  location  of,  by 
Chiene's  method,  247  ;  of  Sylvius,  247  ; 
subfrontal,  249;  superfrontal,  249; 
transverse,  248. 

Fistula,  salivary,  632 ;  Agnew's  operation 
for,  632;  Deguise's  operation  for,  633; 
Desault's  operation  for,  632 ;  Richelot's 
operation  for,  633;  Van  Buren's  opera- 
tion for,  632, 


INDEX. 


Xlll 


Flap,  aiiipiitation,  elliptical,  481;  dural, 
in  oraniotoniy  for  brain  tumor,  253;  for 
rliinopiasty,  588;  for  rhinoplasty,  Kvv- 
gan's,  589;  for  rhinoplasty,  Langen- 
beck's,  589;  for  rliino])lasty.  ])yriforiu, 
of  Dieil'enbach,  58!) ;  for  rhinoplasty, 
triangular,  588;  osteoplastic,  in  lami- 
nectomy, 315;  of  soft  parts,  in  craniot- 
omy for  cerebellar  tumor,  250;  size  of, 
in  plastic  surgery,  509. 

Flaps,  Agnew's  method  of  forming,  in 
thigh  amputations,  535. 

Flaps,  amputation,  circular,  453 :  com- 
parative merits  of  dill'erent  forms  of, 
453,  459;  cutaneous,  452;  double,  472; 
equilateral,  458;  hood,  458;  lateral,  472; 
Lister's  rule  for  length  of,  458;  methods 
of  making,  453;  mixed  double,  Sedillot, 
457;  moditled  circular,  450;  musculo- 
cutaneous, 452;  oval  or  racket,  450; 
periosteal,  452,459;  rectangular,  Teale's, 
458;  semilunar,  Liston's,  450;  single, 
450. 

Flaps,  bone,  in  craniotomy,  251;  classifi- 
cation of,  in  amputations,  452;  depend- 
ent as  a  means  of  drainage,  105;  length 
of,  in  amputation,  451;  methods  of 
transfer  of,  in  plastic  surgery,  571;  mi- 
gratory, in  plastic  surgery,  571;  nutri- 
tive integrity  of,  after  amputation,  452 ; 
osteoplastic,  530;  osteoplastic,  in  ura- 
noplasty, 025. 

Flaps,  transfer  of,  in  plastic  surgery,  571; 
by  grafting,  575 ;  by  inversion  and  ever- 
sion,  574;  by  jumping,  574;  by  sliding 
in  a  curved  line,  572;  by  sliding  in  a 
direct  line,  571;  by  Tagliaeotiau  meth- 
od, 574. 

Fletcher's  aneurism  needle,  130. 

Flexor  carpi,  radialis,  tenotomy  of, 
331;   ulnaris,  tenotomy  of,  331. 

Flexor  longus  digitorum,  tenotomy  of, 
332 ;  precautions  in  tenotomy  of,  333. 

Flexor  longus  pollicis,  tenotomy  of,  333. 

Flexor  profoundus  digitorum,  tenotomy 
of,  331. 

Flexor  sublimis  digitorum,  tenotomv  of, 
331. 

Floss  silk  stay  knot,  84. 

Fluhrer's  probe,  207. 

Focal  epilepsy,  results  of  operations  for, 
257. 

Food,  after  anaesthesia,  21. 

Foot,  amputation  of,  Bruns's,  515;  Es- 
march's  modification  of  Le  Fort's,  515 ; 
Fergusson's  modification  of  Pirogofi's. 
513;  Le  Fort's  modification  of  Piro- 
gotf's,  514;  Pirogofi's,  512;  Pirogoft"s, 
remarks  on  and  results  of,  513;  results 
of,  515. 

Forbes's  modification  of  Chopart's  ampu- 
tation at  mediotarsal  joint,  505. 

Forceps,  77;  bone-cutting,  Liston's,  405; 
bone-holding,  304;  bone,  in  dislocation 
and  fracture  of  humerus,  392 ;  Fergus- 
son's  lion-jawed,  405;  Farabeuf's,  405; 


for  correction  of  deviation  of  septum 
nasi,  001 ;  Hofmann's  bone-cutting, 
242;  needle,  99;  throat,  004;  thumb, 
40,  129;  thumb,  with  claw  bite,  47; 
thumb,  mouse  tooth,  129;  tongue,  13, 
119;   torsion,  77. 

Forcipressure,  78-129. 

Forewarn!  amputation,  479;  anatomical 
points  for,  479;  circular  skin-flap  meth- 
od, 479;  comments  on,  481;  equilateral 
skin-fiap  method,  480;  Jacobson's  pos- 
terior flap  in,  480 ;  musculo-cutaneous 
method  of,  480;  results  of,  481. 

Foreign  bodies,  found  Avithin  the  brain 
after  gunshot  wound,  200;  in  air  pas- 
sages, 098;  in  air  passages,  comments 
on,  099 ;  in  air  passages,  results,  700 ;  in 
air  passages,  treatment  of,  099 ;  in 
oesophagus,  004;  in  oesophagus,  intra- 
thoracic portion,  070 ;  in  cesophagus, 
remarks  on,  005. 

Foreign  bodv  in  bronchus,  099 ;  in  larynx, 
098;  in  trachea,  098. 

Fork  as  a  retractor^  129. 

Fountain  syringe  as  an  irrigator,  108. 

Fowler's  inhaler,  20 ;  method  of  sterilizing 
catgut,  87;  operating  table,  55;  opera- 
tion for  webbed  fingers,  500. 

Fracture  of  larynx  or  hyoid  bone,  724;  of 
skull,  craniotomy  for,  231. 

Frazer's  method  of  intracranial  division 
of  trifacial  nerve,  300. 

French  method  of  rhinoplasty,  580. 

Fresh  air  during  shock,  121. 

Friction  knot,  82. 

Frontal  sinus,  trephining,  205. 

Functions  of  bones,  350. 

Furneaux-Jordan  amputation  at  hip 
joint,  554. 

Fusiform  aneurism,  radical  cure  of,  207. 

Gag,  mouth,  119;   Denhard's,  285;   Good- 

willie's,  285. 
Gait's  trephine,  231. 
Galvano-cautery,    80;     in     bronchotomy, 

090. 
Ganglion,   352;    Meckel's,  278;    operative 

methods  for  cure  of,  352. 
Gangrene  following  ligature  of  the  femoral 

vein,  215;  use  of  the  elastic  bandasie  in, 

70. 
Gant's  method  of  osteotomy  of  shaft   of 

femur,  438. 
"  Gas  and  ether  "  anresthesia,  death-rate 

in,  22. 
Gas  and  ether  before  chloroform,  34. 
Gas  and  oxygen  am^sthesia,  33. 
Gas  before  ether,  34. 
Gastrotomy,  071,  073;  comments  on.  671; 

instruments   for,    071;    precautions    in, 

071. 
Gauze,  bichloride.  111:  dressing  for  oper- 
ation  wound.    107 ;    improvised   aseptic 

and    antiseptic,     112;     iodoform,     110; 

iodoform,  in  septic  cases,  95;    packing, 

to  arrest  bleeding,  96;  pads,  aseptic,  63; 


XIV 


INDEX. 


quality  used  at  Bellevue  Hospital,  112; 
strips  for  drainage,  106;  Thiersch's, 
111. 

Gelatin  as  an  hsemostatic,  66. 

General  considerations  in  ligature  of  ar- 
teries, 125;  distinction  between  arteries 
and  veins,  126;  guides  to  arteries,  125; 
kind  of  instruments  required,  129; 
modes  of  ligaturing,  125;  opening  of 
sheath  of  vessels,  127 ;  passage  of  liga- 
ture, 127,  128;  position  of  part,  126; 
primary  incision,  126;  selection  of  site 
for,  126;   tying  of  ligature,  129. 

General  considerations  of  amputations, 
451. 

General  considerations  of  operative  sur- 
gery, 1 ;  age,  2 ;  diet,  9 ;  nursing,  9 ;  oc- 
cupation, 3 ;  physical  condition,  3 ;  place 
for  operation,  7 ;  relation  of  surgeon  to 
patient,  1 ;  requirements  for  operation, 
9 ;  sex,  3  ;  sick-room,  8  ;  time  for  opera- 
tion, 7. 

General  remarks  on  preparation  for  oper- 
ation, 95. 

Gensoul's  incision  for  complete  excision 
of  upper  jaw,  368. 

Genu  valgum,  anatomical  points  for  oper- 
ations for,  442;  operations  for,  442;  os- 
teo-arthrotomy  for,  Chiene's,  444 ;  osteo- 
arthrotomy for,  Ogston's,  443 ;  osteo- 
arthrotomy for,  Reeves's,  443 ;  osteo-ar- 
throtomy  for,  results  of,  444;  supracon- 
dyloid  osteotomy  for,  Macewen's,  443; 
supracondyloid  osteotomy  for,  results, 
443. 

Genu  varum,  osteotomy  for,  444;  osteot- 
omy for,  results,  445. 

Gerster's  method  of  tamponing  the  tra- 
chea, 707. 

Gersuny's  method  of  meloplasty,  618. 

Gibney's  method  of  shortening  tendo 
Achillis,   342. 

Gigli-Haertel  saw,  243;  saw  for  excision 
of  bone,  364. 

Giraldes's  operation  for  single  harelip,  602. 

Girard's  operation  for  diverticula  of  the 
oesophagus,  681. 

Girdner's  telephone  probe,  267. 

Gland,  parotid,  anatomical  points  of,  734 ; 
contra-indications  to  extirpation  of, 
735;  extirpation  of,  734;  results  of  ex- 
tirpation of,  737. 

Glands,  lymphatic,  cervical,  incisions  for 
removal  of,  728;  Hartley's  operation  on, 
730;  Johns  Hopkins  Hospital  operation 
on,  Mitchell's,  731;  removal  of,  727; 
results  of  removal  of,  733;  treatment 
after  removal  of,  733;  Treves's  opera- 
tion on,  729. 

Gleiss's  method  of  nerve  suture,  274. 

Glover's,  the,  suture,  102. 

Gloves,  antiseptic,  114;    cotton,  115. 

Gluteal  artery,  anatomical  points  of,  136; 
artery,  ligature  of,  136;  nerve,  exposure 
of,  324. 

Glycosuria  after  anaesthesia^  21. 


Goitre,  ansesthesia  for,  716;  angular  in- 
cision foi%  714;  dangers  of  operations 
on,  722;  dislocation  of  the,  712;  enucle- 
ation of,  717,  718;  enucleation-resection 
of,  Kocher's,  717;  enucleation-resection 
of,  comments  on,  718;  enucleation- 
resection  of,  precautions  in,  718;  exoph- 
thalmic, excision  of  sympathetic  for, 
Jaboulay  and  Jonnesco's,  721;  injection 
of,  721;  intrathoracic,  removal  of,  717; 
precautions  for  excision  of,  715;  recur- 
rent, 720;  resection  of,  Kocher's,  719; 
treatment  of,  by  ligature  of  thyroid 
arteries,  720;  Trendelenburg's  opera- 
tion for,  721. 

Goodwillie's  mouth  gag,  285. 

Gouging  of  calcaneum,  409;  of  carious 
bone,  356;  of  carious  bone,  comments 
on,  356. 

Goyraud's  operation  for  Dupuytren's  con- 
traction, 351. 

Gracilis,  tenotomy  of,  336. 

Grad's  method  of  loosening  ligatures,  85. 

Grafting,  skin,  575. 

Grant's  method  of  eheiloplasty  for  lower 
lip,  606. 

Graves's  disease,  721. 

Great  toe,  amputation  of,  498;  by  inter- 
nal plantar-flap  method,  Farabeuf's, 
499 ;  by  oval-flap  method,  499 ;  by 
square-flap  method,  498 ;  first  phalanx 
of,  496,  497 ;  with  metatarsal  bone, 
501;   through  last  phalanx,  497. 

Great  toe,  excision  of  metatarso-phalan- 
geal  joint  of,  408. 

Green  soap,  confined,  in  preparation  of 
area  for  operation,  95;  for  cleansing  the 
hands,  114. 

Gridiron  incision  for  ligature  of  external 
iliac  artery,  140. 

Gritti's  osteoplastic  amiDutation  of  thigh, 
529. 

Grooved  director,  47,  129. 

Gross's  artery  compressor,  78. 

Guerin's  operation  for  nasal  growths,  659. 

Guide,  bony,  to  carotid  artery,  external, 
195;  to  carotid  artery,  internal,  196; 
to  lingual  artery,  198;  to  subclaAnan 
artery,  second  and  third  portions,  172; 
to  temporal  artery,  201 ;  to  thyroid  ar- 
tery, inferior,  178;  to  vertebral  artery, 
175. 

Guide,  linear,  to  abdominal  aorta,  130, 
131 ;  to  axillary  artery,  first  portion, 
178;  to  axillary  artery,  third  portion, 
179;  to  brachial  artery,  181;  to  carotid 
artery,  common,  191;  to  carotid  artery, 
external,  194;  to  carotid  artery,  inter- 
nal, 196;  to  dorsalis  pedis  artery,  153; 
to  epigastric  artery,  deep,  141;  to  fem- 
oral artery,  143;  to  gluteal  artery,  136; 
to  iliac  artery,  common,  132,  133;  to 
iliac  artery,  external,  138;  to  iliac  ar- 
tery, internal,  135;  to  mammary  artery, 
internal,  177;  to  lingual  artery,  198; 
to  palmar  arches,  190;  to  peroneal  ar- 


INDEX. 


XV 


tery,  155;  to  popliteal  artery,  149;  to 
pudie  artery,  internal,  138;  to  radial 
arteiy,  18G;  to  sciatic  artery,  137;  to 
subclavian  artery,  second  portion,  174; 
to  subclavian  artery,  tliinl  portion,  171 ; 
to  tibial  artery,  posterior,  1.14;  to  tibial 
artery,  anterior,  151 :  to  thyroid  artery, 
inferior,  177;  to  ulnar  arterj',  188;  to 
vertebral  arterj^^  175. 

Guide,  muscular,  to  axillary  artery,  first 
portion,  178;  to  axillary  artery,  third 
portion,  180;  to  brachial  artery,  181; 
to  carotid  artery,  connnon,  191;  to  ca- 
rotid artery,  external,  194;  to  carotid 
artery,  internal,  19(j ;  to  dorsalis  pedis 
artery,  153;  to  facial  artery,  200;  to 
femoral  artery,  143;  to  iliac  artery, 
common,  133;  to  iliac  artery,  external, 
139;  to  iliac  artery,  internal,  135;  to 
popliteal  artery,  149;  to  radial  artery, 
18G;  to  sciatic  artery,  137;  to  subcla- 
A'ian  artery,  second  portion,  174;  to  sub- 
clavian artery,  second  and  third  por- 
tions, 171;  to  tibial  artery,  anterior, 
151;  to  tibial  artery,  posterior,  154;  to 
ulnar  artery,  188;  to  vertebral  artery, 
175. 

Guide,  to  inferior  dental  nerve,  deep,  285; 
to  inferior  dental  nerve,  superficial, 
285;  to  subclavian  artery,  first  portion, 
left  side,  168;  to  subclavian  artery,  first 
portion,  right  side,  170;  to  subclavian 
artery,  third  portion,  jugular  vein  as  a, 
172. 

Guides,  bony,  to  facial  nerve,  307. 

Guides,  to  arteries,  125;  to  innominate 
artery,  158;  to  lingual  or  gustatory 
nerve,  289;  to  subclavian  artery,  168; 
to  trifacial  nerve  in  intracranial  neu- 
rectomy, 300. 

Gunshot  wounds  of  the  cranium,  266; 
after-treatment  of,  270;  foreign  bodies 
found  within  the  brain  in,  266;  location 
of  bullet  in,  267;  operation  for,  266; 
removal  of  bullet  after,  268;  steps  in 
treatment  ofj  266. 

Gussenbauer's  artificial  larynx,  708; 
method  of  meloplasty,  617. 

Gustatory  nerve,  288;  anatomical  points 
of,  288;  guides  to,  289. 

Guthrie's  antero-posterior-flap  method  of 
amputation  at  the  hip,  555. 

Guyon"s  supramalleolar  amputation  of 
leg,  516. 

Gyrus,  angular  (brain),  250. 

Haemophilia,  6;  action  of  calcium  chlorid 
in,  67. 

Haemorrhage,  after  bronchotomy,  691 ; 
after  complete  removal  of  tongue 
through  mouth,  639;  after  enucleation 
of  thyroid  body,  717;  after  laminec- 
tomy, 311;  after  removal  of  tonsil,  633; 
agents  for  the  control  of,  65;  arrest  of 
middle  meningeal,  239;  control  of,  in 
excision  of  upper  jaw,  369;  during  oper- 


ations on  harelip,  598;  during  opera- 
tions on  tongue,  634;  iluring  operations 
on  tongue,  Langenbeck's  method  of  con- 
trolling, 634;  elastic  l)andage  after,  70; 
epidural,  238;  from  gunsliot  wounds  of 
cranium,  266;  from  pia,  arrest  of,  241; 
from  pia  in  craniotomy,  253;  from 
sinuses,  238;  in  circular  craniotomy, 
236;  in  craniotomy  for  lateral  sinus 
thrombosis,  261;  in  craniotomy  for  tu- 
mor, 251 ;  indications  of  progressive, 
238;  in  laryngotomy,  690;  in  linear 
craniotomy,  244 ;  in  operations  on  sec- 
ond portion  of  trifacial  nerve,  283;  in 
typhoid  fever,  Coleman's  method  of  con- 
trolling, 66;  Keen's  method  of  arresting, 
in  intracranial  neurectomy,  299;  liga- 
ture of  third  portion  of  subclavian  for, 
174;  methods  for  control  of,  in  amputa- 
tion at  hip  joint,  540;  middle  menin- 
geal, 238;  secondary,  72,  77;  subdural, 
238,  240. 

Hcemostatic,  artificial,  65;  natural,  65; 
position  as  an,  68. 

Hremostatics,  artificial,  adrenalin  chlo- 
rid, 66 ;  acupressure,  75  ;  bandages,  68  ; 
Buck's  pin  and  carrier,  76;  calcium 
chlorid,  67;  cautery,  79;  circum- 
clusion,  76;  circumferential  elastic 
pressure  as  an,  242;  compresses,  grad- 
uated, 71;  compresses,  simple,  71; 
Davy's  lever,  73;  digital  pressure,  71; 
Esmarch's  elastic  bandage,  69;  extem- 
porized tourniquet,  72;  forceps,  77; 
forcipressure,  78;  gelatin,  66;  Gross's 
compressor,  78;  instrumental  pressure, 
72;  ligature,  81;  Petit's  tourniquet, 
72;  pins,  76;  retroclusion,  76;  rubber 
rings,  70;  serre-fines,  77;  Simpson's 
method  of  acupressure,  75 ;  styp- 
tics, 68 ;  suprarenal  extract.  66 ;  tenac- 
ula,  77,  78;  thermic  angiotribe,  79; 
torsion,  76;  torsoclusion,  76;  Trendelen- 
burg's rod,  74;  Wveth's  pins,  75. 

Haertel  saw,  243,  364. 

Hagedorn's  operation  for  double  compli- 
cated harelip,  604;  for  single  harelip, 
601. 

Hahn's  method  of  tamponing  the  trachea, 
707. 

Halsted's  ligature  of  subclavian  artery, 
left  side,  first  portion,  170;  method  of 
sterilizing  and  preserving  ligatures  and 
sutures,   91;    subcuticular   suture,    104. 

Halux  valgus,  446;  cuneiform  osteotomy 
for,  447 ;  linear  osteotomy  for,  447 ;  re- 
moval of  head  of  metatarsal  bone  for, 
447. 

Hamilton's  foi-ceps,  77. 

Hammer  toe,  treatment  of,  562. 

Hamstring  uuiscles,  tenotomy  of,  336. 

Hancock's  amputation  at  the  astragalus, 
508. 

Hands,  method  of  cleansing,  at  Johns 
Hopkins  Hospital,  114;  method  of 
cleansing  for  an  operation,  114;  nascent 


XVl 


INDEX. 


chlorine    method     of    cleansing,     114; 
preparation  of,  for  an  operation,  113. 

Hardie's  modification  of  Goyraud's  opera- 
tion for  Dupuytren's  contraction,  351. 

Harelip,  596;  control  of  patient  during 
operation  for,  596;  instruments  em- 
ployed in  operation  on,  598;  operation 
for,  599 ;  suture,  102 ;  time  for  operation 
on,  596. 

Harelip,  complicated,  603 ;  management  of 
projecting  intermaxillary  bone  in,  603. 

Harelip,  double,  603. 

Harelip,  double,  complicated,  Hagedorn's 
operation  for,  604;  operation  for,  604; 
Owen's  operation  for,  605 ;  results  of  op- 
erations for,  605;  treatment  after  oper- 
ations for^  605. 

Harelip,  single,  600;  Dieffenbach's  opera- 
tion, 602 ;  double-flap  operation,  Mal- 
gaigne,  600;  Giraldes's  operation,  602; 
Hagedorn's  operation,  601 ;  Konig's  op- 
eration, 602;  Simon's  operation,  601; 
single-flap  operation,  Mirault's,  600. 

Hartley-Krause  method  of  intracranial 
neurectomy  of  the  trifacial,  296. 

Hartley's  chisel,  298;  incision  for  removal 
of  cervical  lymphatic  glands,  728;  oper- 
ation upon  cervical  lymphatic  glands. 

Hartmann's  rule  in  opening  the  mastoid 
antrum,  264. 

Head,  lowering  of,  in  shock,  121;  position 
of,  in  intracranial  neurectomy  of  the 
trifacial.  Keen's,  299. 

Headache  after  anaesthesia,  20. 

Heart,  aspiration  of,  123. 

Heart  failure,  rise  of  adrenalin  in,  67. 

Heat  as  an  antiseptic,  62. 

Heath's  method  of  tying  the  reef  knot,  83. 

Hemp  ligatures,  81. 

Hey's  amputation  of  leg,  middle  third, 
520 ;  modification  of  List ranc's  tarso- 
metatarsal amputation,  504. 

Hill's  method  of  treating  syncope  during 
anaesthesia,  19. 

Hip,  arthrotomy  for  dislocations  at,  431. 

Hip,  congenital  displacement  of,  Lorenz's 
operation  for,  440;  Lorenz's  operation 
for,  remarks  on,  440 ;  Lorenz's  opera- 
tion for,  results  of,  440;  Hoffa's  opera- 
tion for,  439;  Hoff'a's  operation  for,  re- 
marks on,  439;  Hoffa's  operation  for, 
results  of,  440;  Hoft'a's  operation  for, 
treatment  after,  439. 

Hip-joint  amputation,  540 ;  anterior-rack- 
et method,  550;  antero-posterior-flap 
method,  Guthrie,  555;  bloodless,  Senn, 
546;  circular-flap  method,  Dieflfenbach, 
552;  control  of  haemorrhage  in,  73,  540; 
Furneaux-Jordan  method,  554;  exter- 
nal-racket method,  549 ;  Lister's  modifi- 
cation of  external-racket  method,  550; 
Lloyd's  method  of  controlling  haemor- 
rhage in,  545;  long  anterior  and  short 
posterior  flap  method,  Manec,  551;  Mc- 
Burney's  method  of  controlling  haemor- 
rhage in,  545;  methods  of,  549;  results 


of,  546,  557 ;  shock  after,  546 ;  single- 
flap  method,  Malgaigne's,  555;  Tilden 
Brown's  clamp  for  controlling  hsemor- 
rhage  in,  546;  tourniquet  for  control  of 
htemorrhage  in,  540;  treatment  after, 
557  ;  Trendelenburg's  rod  for  controlling 
haemorrhage  in,  542;  Wyeth's  method 
for  controlling  haemorrhage  in,   542. 

Hip  joint,  disarticulation  at,  540. 

Hip  joint,  excision  of,  425;  Barker's,  428; 
conservative  subperiosteal  operation, 
Langenbeck's,  427;  Farabeuf's,  428; 
general  remarks  on,  429;  radical  opera- 
tion, White's,  426;  results,  430;  Sayre's, 
429;  treatment  after,  430. 

Hoffa's  operation  for  congenital  displace- 
ment of  hip,  439;  remarks  on,  439;  re- 
sults of,  440;  treatment  after,  439. 

Hofmann's  bone-cutting  forcei^s,  242. 

Holden's  maxim,  236. 

Holders,  needle,  99. 

Hooks,  tension  with,  before  sewing,  99. 

Horsehair,   sutures,   98;    drainage,    106. 

Horsley's,  fissure  meter,  246;  incision  for 
inferior  dental  nerve,  287;  intradural 
division  of  the  trifacial  nerve,  307 ;  oper- 
ation for  bi'ain  tumor,  254;  wax,  236. 

Hot  water   bags  during  shock,   121. 

Hot  water  in  the  arrest  of  haemorrhage, 
68. 

Hot  water   mattress,   Crile's,  55. 

Housemaid's  knee,  treatment  of,  353. 

Hueter's,  method  of  tendon  suturing,  340 ; 
oblique  incision  for  excision  of  upper 
end  of  humerus,  385;  operation  for  ex- 
cision of  elbow  joint,  395;  operation  on 
the  tongue,  638. 

Humerus,  amputation  at  surgical  neck  of, 
485;  anatomical  points  for,  485;  oval 
method,  Guthrie's,  486;  single  external- 
flap  method,  Farabeuf's,  486. 

Humerus,  arthrotomy  for  irreducible  dis- 
location of,  391. 

Humerus,  excision  of,  384;  complete,  395; 
lower  extremity  of,  394;  shaft  of,  394; 
through  Langenbeck's  vertical  incision, 
385;  upper  extremity,  385. 

Humerus,  habitual  dislocation  of,  opera- 
tion for,  393. 

Hunter's  canal,  femoral  artery  in,  143. 

Hydrocephalus,  acute,  229;  results  of 
operation  in,  229;  chronic,  227;  chron- 
ic, drainage  agents  in,  228. 

Hydrogen  peroxide,  61;  in  septic  cases,  95. 

Hyoid  bone,  fracture  of,  724. 

Hypertrophy  of  tongue,  637. 

Hypodermic  injections  during  ansesthesia, 
14. 

Hypodermic  syringe,   119. 

Hypodermoclysis,  222;  in  shock,  121. 

Hysterical  patients,  operations  on,  6. 

Ice  as  an  anaesthetic,  36. 

Iliac  arteries,  common,  ligature  of,  131; 
common,  relations  of,  132;  common, 
linear  guide  to,  132;   deep   circumflex, 


INDEX. 


XVll 


ligature  of,  142;  external,  anatomical 
points  of,  138;  eternal,  gridiron  inci- 
sion in  ligature  of,  140;  external.,  liga- 
ture of,  138;  external,  linear  guide  to, 
138;  external,  relations  of,  139;  inter- 
nal, ligature  of,  135;  internal,  rela- 
tions of,  135. 

Immobility  of  inferior  maxilla,  377;  divi- 
sion of  the  neck  of  the  bone  for,  378; 
Esmarch's  operation  for,  377 ;  excision 
of  condyle  for,  378 ;  remarks  on  excision 
of  condyle  for,  379;  Ilizzoli's  operation 
for,  378. 

Important  considerations  in  treatment  of 
an  operation  wound,  96. 

Improvised  aseptic  and  antiseptic  gauze, 
112. 

Incision  and  ligaturing  of  varicose  veins, 
217. 

Incision,  forms  of,  in  linear  craniotomy, 
242 ;  Phelps's  open,  for  talipes  equino 
tarus,  448;  Phelps's  open,  for  talipes 
equino-varus,  results,  449 ;  primary,  in 
ligature  of  arteries,  126;  primary,  in 
ligature  of  internal  iliac,  135. 

Incisions,  for  buccal  nerve,  290 ;  varieties 
of,  49. 

Inclined  plane,  portable,56 ;  improvised,56. 

Indian  operation  of  rhinoplasty,  586. 

Infected  tissue,  drainage  of,  105. 

Infection  from  sponges,  62. 

Inferior  dental  nerve,  284;  exposure  of, 
285 ;  exposure  of,  in  dental  canal,  288 ; 
external  or  facial  route  to,  286;  com- 
ments on  operation  on,  286;  guides  to, 
285,  286;  Horsley's  incision  for,  287; 
internal  or  buccal  route  to,  285 ;  Keen's 
incision  for,  287;  Kiihn's  incision  for, 
287 ;  Liirhart's  incision  for,  287 ; 
Llicke's  incision  for,  287 ;  operation  on, 
285 ;   precautions  in   operation  on,  286. 

Inferior  maxilla,  immobility  of,  377. 

Infiltration,  anaesthesia,  Schleich's  meth- 
od, 38;  intraneural,  38;  method  of  in- 
troducing fluid,  39;  regional  paraneu- 
ral, 38. 

Infraorbital  nerve,  operations  on,  277. 

Infusion,  arterial,  223 ;  venous,  220 ; 
venous,  amount  of  solution  introduced 
in,  221. 

Ingrown  toe-nail,  567;  Anger's  opei-ation 
for,  567;  Cotting's  operation  for,  568; 
results  of  operation  for,  568. 

Inhaler,  Allis's,  25;  Bennett's,  28-33; 
Clover's,  26;  Esmarch's,  30;  Fowler's, 
26;  Junker's,  30;  Ormsby's,  27;  Skin- 
ner's, 30. 

Inhalers,  chloroform,  30;  ether,  24. 

Injection,  of  a  meningocele,  230  ;  of  birth- 
marks with  ergot,  224;  of  hot  water 
into  vascular  growths  (Wyeth),  226; 
of  hot  water  into  vascular  growths,  re- 
marks on,  226;  of  hot  water  into  vas- 
cular growths,  results  of,  226;  of  iodine 
solution  into  the  ventricles,  228;  of  sa- 
line solution  into  the  ventricles,  228 ;  of 
40 


saline  solutions,  221;  of  varicose  veins, 
216;  of  varicose  veins,  results,  216. 

Innominate  artery,  anatomical  points  of, 
158;  guides  to,  158;  ligature  of,  158; 
relations  of,  158. 

Inorganic  ligatures,  81;  sutures,  97. 

insane,  craniotomy  for  general  paralysis 
of,  261;  operations  on,  6;  tapping  ven- 
tricles for  general  paralysis  of,  261. 

Insanity  after  anaesthesia,  21. 

Instrumental  pressure  as  an  haemostatic, 
72. 

Instruments,  44;  action  of  sodium  car- 
bonate on,  62;  construction  and  finish 
of,  44;  cutting,  estimation  of  quality 
of,  44;  in  general  use,  44,  45;  for  special 
23urposes,  44;  necessary  for  operations, 
44;  sterilization  of,  112,  152;  prepara- 
tion of,  for  an  operation,  113;  recepta- 
cles for,  51;  selection  of,  44;  solutions 
suitable  for,  52 ;  required  to  ligature 
arteries  in  continuity,  129. 

Integumentary  flaps,  amputation,  452. 

Internal  carotid  artery,  196;  iliac  artery, 
ligature  of,  135 ;  mammary  artery,  ana- 
tomical points  of,  177;  mammary  ar- 
tery, ligature  of,  177;  mammary  artery, 
linear  guide  to,  177;  or  buccal  route  to 
inferior  dental  nerve,  285 ;  pudic  artery, 
anatomical  points  of,  138;  pudic  artery, 
ligature  of,  137. 

Interrupted  suture,  101 ;  removal  of,  102. 

Intrabuccal  operation  on  buccal  nerve, 
290;  route  to  lingual  nerve,  289. 

Intracranial  neurectomy  of  trifacial 
nerve,  295;  Abbe's  method,  306;  com- 
plications in,  300;  Cushing's  method, 
303;  Doyen's  method,  302;  Hartley- 
Ivrause  method,  296;  methods  of,  295; 
precautions  in,  300;  remarks  on,  301; 
results  of,  301;  Rose's  method,  295; 
sequels  of,  301. 

Intraneural  infiltration  anresthesia,  38. 

Intraparietal  fissure,  localizing  of,  249. 

Intraspinal  division  of  the  roots  of  spinal 
nerves,  321;  remarks  on,  321;  results 
of,  321. 

Intrathoracic  goitre,  removal  of,  717. 

Intravenous  injection  during  shock,  121; 
use  of  adrenalin,  67. 

Intubation  of  larynx,  693;  apparatus  for, 
O'Dwyer's,  694;  method  of,  694;  pre- 
cautions in,  696;  results  of,  698;  treat- 
ment after,  697. 

Iodine,  injection  of,  in  goitre,  Schwartz's, 
722 ;  solution,  injection  of,  into  ventri- 
cles, 228 :   solutions  of,  60. 

Iodoform,  109;  objections  to  use  of,  112; 
pulverized,  109. 

Iodoform  and  ether,  saturated  solution 
of,  61. 

Iodoform  gauze,  110;  composition  of-.  111 ; 
in  septic  cases,  95;  percentage  of  iodo- 
form in,  110;  preparation  of,  at  Belle- 
vue  Hospital,  110;  strips  for  drainage, 
106. 


xvm 


INDEX. 


lodoglyeerine  solution^  injection  of,  in 
spina  bifida,  317. 

lodol,  110. 

Iron  subsulphate  as  a  styptic,  68. 

Irrigator,  fountain  syringe  as  an,  108. 

Isolation  ring  in  cocaine  ansesthesia, 
38. 

Israel's  method  of  meloplasty,  617;  modi- 
fication of  Konig's  operation  of  osteo- 
plastic rhinoplasty,  591. 

Italian  operation  of  rhinoplasty,  590. 

Jaboulay's  excision  of  the  sympathetic 
for  exophthalmic  goitre,  721;  exothyro- 
pexy,  721. 

Jacket  of  jjlaster  of  Paris  for  curvature 
of  spine,  560. 

Jacksonian  epilejjsy,  results  of  operations 
for,  257. 

Jacobson's  posterior  flap  in  amputation  of 
forearm,  480. 

Jaeger's  method  of  removal  of  tongue, 
641. 

Jaesche-Dieffenbach  method  of  flap  trans- 
fer in  plastic  surgery,  573. 

Jaundice,  after  antestliesia,  21. 

Jaw,  division  of,  in  removal  of  tongue, 
640;  excision  of  upper,  365. 

Jaw-pry,  author's  wooden,  14. 

Johns  Hopkins  Hospital  operation  on  cer- 
vical lymphatic  glands,  Mitchell,  731. 

Joint,  anchylosed,  Brisement  force  in, 
558. 

Joint,  ankle,  amputation  at,  509 ;  arthrec- 
tomy  of,  Bruns's,  425;  excision  of,  411 ; 
landmarks  of,  412. 

Joint,  elbow,  amputation  at,  481;  exci- 
sion of,  395. 

Joint,  erasion  of,  424. 

Joint,  false,  formation  of,  at  hip,  437. 

Joint,  hip,  amputation,  540;  anterior 
racket  method,  550 ;  antero-posterior- 
flap  method,  Guthrie's,  555;  bloodless, 
Senn's,  546 ;  circular-flap  method,  Dief- 
fenbach's,  552;  control  of  haemorrhage 
in,  540;  extei'nal-racket  method,  549; 
Furneaux- Jordan  method,  554 ;  Lister's 
modification  of  external-racket  method, 
550;  Lloyd's  method  of  controlling 
hemorrhage  in,  545;  long  anterior  and 
short  posterior-flap  method,  Manec's, 
551;  McBurney's  method  of  controlling 
haemorrhage  in,  545;  methods  of,  549; 
results,  546,  557;  shock  after,  546;  sin- 
gle-flap method,  Malgaigne's,  555;  Til- 
den  Brown's  clamp  for  controlling  haem- 
orrhage in,  546;  tourniquets  for  control 
of  haemorrhage  in,  540 ;  treatment  after, 
557;  Wyeth's  method  of  controlling 
haemorrhage  in,  542. 

Joint,  hip,  disarticulation  at,  540;  exci- 
sion of,  425. 

Joint,  knee,  amputation,  523 ;  bilateral- 
flap  method  of  Stephen  Smith,  523;  cir- 
cular-flap method,  526;  elliptical-inci- 
sion method,  Baudens's,  526 ;  long  ante- 


rior- and  short  posterior-flap  method. 
Pollock's,  527 ;  Stephen  Smith's  method 
for  gangrenous  condition  of  toes  and 
foot,  525;   results,  527. 

Joint,  knee,  bony  anchylosis  of,  441; 
Brisement  force  for,  558. 

Joint,  knee,  excision  of,  416. 

Joint,   knee,  osteotomy  of,  441-558. 

Joint,  medio-tarsal,  amputation  at,  Cho- 
part's,  504. 

Joint,  metatarso-phalangeal,  amputations 
at,  499;  excision  of,  408;  of  great  toe, 
excision  of,  408. 

Joint,  shoulder,  amputation  at,  486;  ex- 
cision of,  390. 

Joint,  wi-ist,  amputation  at,  477;  excision 
of,  400. 

Joints,  metacarpo-phalangeal,  excision  of, 
407;  phalangeal,  excision  of,  407;  pha- 
langeal, of  foot,  excision  of,  407 ;  tarsal, 
operations  on,  408. 

Joints,  tarso-metatarsal,  amputation  at, 
502 ;  excision  of,  408. 

Jonnesco's  excision  of  the  sympathetic  for 
exoplithalmic  goitre,  721. 

Jordan's  amputation  at  the  hip,   554. 

Jugular  vein,  craniotomy  for  thrombosis 
of,  260 ;  external,  as  a  guide  to  the  third 
portion  of  the  subclavian  artery,  172; 
in  ligature  of  the  common  carotid  ar- 
tery, 193;  results  of  ligature  of,  215. 

Junker's  chloroform  apparatus,  30. 

Jury  mast,  Say  re's,  561. 

Jute  dressing,  112. 

Kangaroo  tendon  sutures,  97. 

Keegan's  flap  for  rhinoplasty,  589;  oper- 
ation of  rhinoplasty,  589. 

Keen's  incision  for  inferior  dental  nerve, 
287;  method  of  controlling  haemorrhage 
in  intracranial  neurectomy,  299;  opera- 
tion of  laryngectomy,  704. 

Kemp's  treatment  of  air  in  veins,  124. 

Knee  joint,  amputation  at,  523;  anatom- 
ical points  for,  524 ;  bilateral-flap  meth- 
od of  Stephen  Smith,  524 ;  circular-flap 
method,  526  ;  elliptical-incision  method, 
Baudens's,  526 ;  fallacies  of  bilateral- 
flap  method,  525 ;  long  anterior-  and 
short  posterior-flap  method.  Pollock's, 
527;  methods  of,  524;  results  of,  527; 
Stephen  Smith's  method  for  gangrene 
of  toes  and  foot,  525. 

Knee  joint,  arthrectomy  of,  424;  brise- 
ment force  for  anchylosis  of,  558;  bony 
anchylosis  of,  441 ;  bony  anchylosis, 
treatment  of.  Barton's,  558;  cuneiform 
osteotomy  for  anchylosis  of,  441 ;  dis- 
articulation at,  523;  excision  of,  416; 
excision  of,  by  transverse  incision. 
Bird's,  419;  linear  osteotomy  for  bony 
anchylosis  of,  441 ;  non-subperiosteal 
excision  of,  Mackenzie's,  418;  osteoto- 
my for  bony  anchylosis  of,  558;  results 
after  excision  of,  423;  subperiosteal  ex- 
cision of,   Langenbeck's,  420 ;   subperi- 


INDEX. 


XIX 


osteal  excision  of,  Oilier's,  421 ;  treat- 
ment ot,  after  excision,  423. 

Knife,  aiiij)utaling,  the  Catlin,  402. 

Knives,  amputating,  461 ;  manner  of 
grasping,  462. 

Knots,  82;  friction,  82;  "granny,"  83; 
reef,  83;  square,  83;  Statlordsliire,  84; 
stay,  of  Ballance  and  Edmunds,  84; 
surgeon's,  82. 

Knott's  conical  oesophageal  bougies,  674. 

Kocher's  complete  laryngectomy,  700;  ex- 
cision of  shoulder  joint,  390;  method  of 
removal  of  tongue,  639;  operation 
for  removal  of  nasal  growths,  659;  op- 
eration of  enucleation  resection  of  goi- 
tre, 717;  operation 'of  partial  excision 
of  thyroid  body,  711;  operation  of  re- 
section of  goitre,  719;  operation  on  sec- 
ond division  of  trifacial  nerve,  281 ; 
operation  on  trifacial  nerve  at  foramen 
ovale,  292. 

Konig's  method  of  fixing  bones  after  ex- 
cision of  knee  joint,  423;  method  of 
preparing  catgut,  91;  operation  of  os- 
teoplastic rhinoplasty,  591 ;  operation 
for  single  harelip,  602. 

Kraske's  method  of  meloplasty,  618. 

Ki-ause's  method  of  intracranial  neurec- 
tomy of  trifacial  nerve,  296;  method 
of  skin  grafting,  577. 

Kreolin,  01.' 

Kronlein's  method  of  locating  the  middle 
meningeal  artery,  239 ;  operation  on  tri- 
facial nerve  at  foramen  ovale,  293. 

Kiihn's  incision  for  inferior  dental  nerve, 
287. 

Lallemand's  method  of   meloplasty,  618. 

Laminectomy,  dangers  of,  311;  operation 
of,  312;   results  of,  316. 

Landmarks,  bony,  of  the  skull,  245. 

Lane's  method  of  staphyloplasty,   631. 

Langenbeck's  chin-flap  method  of  cheilo- 
plasty  of  lower  lip,  609 ;  circular  method 
of  cheiloplasty  of  lower  lip,  608 ;  clamp, 
69 ;  excision  of  head  of  humerus,  387 ; 
excision  of  hip  joint,  subperiosteal,  427; 
excision  of  elbow  joint,  subperiosteal, 
396;  excision  of  knee  joint,  subperios- 
teal, 420;  excision  of  upper  end  of  hu- 
merus, vertical  incision  for,  385;  ex- 
cision of  wrist  joint,  complete  subperi- 
osteal, 402 ;  flap  for  rhinoplasty,  589 ; 
hook  for  tracheotomy,  683 ;  method  of 
amputating,  458;  method  of  controlling- 
haemorrhage  during  operations  on  the 
tongue,  634;  method  of  uranoplasty. 
623;  musculo-cutaneous  flaps  in  ampu- 
tation of  arm,  484;  operation  for  re- 
moval of  nasal  growths,  maxillary 
route,  057;  operation  for  removal  of 
nasal  growths,  nasal  route,  655 ;  opera- 
tion for  removal  of  tongue,  642 ;  oper- 
ation of  rhinoplasty,  582;  saw,  433; 
serre-fine  forceps,  78 ;  subperiosteal  ex- 
cision of  ankle  joint,  412. 


Lannelongue's  method  of  uranoplasty, 
625. 

Lurrey's  oval-(la])  ani]5utation  at  tlie 
shoulder  joint,  491. 

Laryngectomy,  700;  general  remarks  on, 
704;  Keen's  method,  704;  complete, 
Kocher's,  700;  complete,  Treves's,  701; 
partial,  703;  Perier's  method,  706;  pre- 
cautions for  and  comments  on,  708; 
precautions  for  partial,  703;  remarks 
on  partial,  703;  results  of,  709;  results 
of  complete,  701 ;  results  of  partial, 
704;  treatment  after,  709;  treatment 
after  complete,  701. 

Laryngo-tracheotomy,  089 ;  instruments 
for,  083 ;    rapid,   Saint-Germain's,  689. 

Laryngotomy,  685;  during  operation, 
119;  instruments  for,  683;  preliminary 
to  operations  on  the  tongue,  635. 

Larynx,  artificial,  708;  fracture  of,  724; 
foreign  body  in,  698. 

Larynx,  intubation  of,  693;  apparatus 
for,  O'Dwyer's,  694;  method  of,  694; 
precautions  in,  696;  results  of,  697; 
treatment  after,  697. 

Lateral  sinus,  relation  of,  to  mastoid  an- 
trum, 202;  thrombosis,  craniotomy  for, 
200.  ' 

Latissimus  dorsi,  tenotomy  of,  337 ;  my- 
otomy of,  338. 

Lawrence's  method  of  removal  of  nasal 
growths,  055. 

Ledran-Mackenzie  method  of  cheiloplasty 
of  upper  lip,  615. 

Lee's  amputation  of  leg  at  middle  third, 
521. 

LeFort's  modification  of  Pirogoff's  ampu- 
tation of  foot,  514. 

Leg,  amputation,  at  lower  third,  516;  au- 
thor's circular,  with  periosteal  flap, 
516;  Duval's  supramalleolar  method, 
516;  Guyon's  supramalleolar  method, 
516;  methods  of,  510;  remarks  on  au- 
thor's circular,  517;  results,  518,  520; 
Teale's  method,  518;  with  bilateral 
flaps,  519;  with  hood  flap,  520;  with 
large  posterior  flap,  518. 

Leg,  amputation,  at  middle  third,  520; 
large  posterior-flap  method,  Hey's,  520 ; 
Lee's  modification  of  Teale's,  521 ;  long 
external-flap  method,  521;  results,  521. 

Leg,  amputation,  at  upper  third,  521; 
bilateral-ilap  or  hood-flap  method,  523; 
circular-flap  method,  522;  large  exter- 
nal-flap method,  Farabeuf's,  521;  re- 
sults, 523. 

Leg  amputation,  osteoplastic.  Bier  and 
Eiselsberg,  530;  treatment  after,  523. 

Leg,  ani|uitalions,  515. 

Leg,  excision  of  bones  of,  410. 

Leucocythoemia,  6. 

Lever,  Davy's,  73. 

Ligaments,  result  of  traumatism  and  dis- 
ease on.  348. 

Ligamentum  patelhf,  elongation  or  rup- 
ture of,  348. 


XX 


INDEX. 


Ligature,  en  masse,  96. 

Ligature  of  abdominal  aorta,  130;  Coop- 
er's method,  130;  Murray's  method, 
131;  results  of,   131. 

Ligature  of  an  artery,  primary  incision 
for,  126. 

Ligature  of  arteries,  general  considera- 
tions of,  125;  in  continuity,  125. 

Ligature  of  axillary  artery,  178;  first  por- 
tion, 178,  179;  first  portion,  fallacies 
and  results  of,  179;  second  portion, 
179;  third  portion,  179;  third  portion, 
fallacies  and  results  of,  180;  three 
points  for,  178. 

Ligature  of  brachial  artery,  180;  falla- 
cies of,  183;  results  of,  185. 

Ligature  of  carotid  arteries,  common, 
both,  193;  results,  193. 

Ligature  of  carotid  artery,  common,  191; 
above  omohyoid  bone,  192;  below  omo- 
hyoid bone,  192;  fallacies  of,  193;  for 
haemorrhage  of  its  divisions,  193;  tem- 
porary, 194;  three  points  for,  192;  re- 
sults, 193. 

Ligature  of  carotid  artery,  external,  194; 
above  digastric  muscle,  196;  below  di- 
gastric muscle,  195;  precautions  and 
fallacies  of,  below  digastric  muscle, 
195;  results,  196;  situations  for, 
195. 

Ligature  of  carotid  artery,  internal,  196; 
fallacies  of,  197;  point  of  election  for, 
196;  results,  196. 

Ligature  of  the  external  circumflex  ar- 
tery, 148. 

Ligature  of  dorsalis  pedis  artery,  153 ; 
of  dorsalis  pedis,  fallacy  of,  153. 

Ligature  of  dorsalis  penis  artery,  138. 

Ligature  of  deep  epigastric  artery,  141. 

Ligature  of  facial  artery,  200;  at  angle 
of  mouth,  201;  at  ramus  of  jaw,  200; 
fallacies  in,  201;  in  neck,  200;  three 
situations  for,  200. 

Ligature  of  femoral  artery,  142;  at  apex 
of  Scarpa's  triangle,  143;  below  Pou- 
part's  ligament,  143;  common,  143; 
common,  danger  of,  143;  deep  (profun- 
da), 148;  deep,  fallacies  in,  148;  falla- 
cies in,  146;  in  Hunter's  canal,  143; 
superficial,   145;   results,   148. 

Ligature  of  femoral  vein,  215;  gangrene 
following,  215;  lateral,  215. 

Ligature  of  gluteal  artery,  136;  fallacies 
of,  136;  results  of,  136. 

Ligature  of  iliac  artery,  common,  131; 
extraperitoneal,  133;  extraperitoneal, 
dangers  and  fallacies  of,  134;  results, 
133,  135;   transperitoneal,  12. 

Ligature  of  iliac  artery,  deep  circumflex, 
142;  at  internal  abdominal  ring,  142; 
at  superior  spinous  process  of  ilium, 
142. 

Ligature  of  iliac  artery,  external,  138; 
extraperitoneal,  139;  fallacies  in,  140; 
gridiron  incision  for,  140;  results,  140; 
transperitoneal,  140. 


Ligature  of  iliac  artery,  internal,  135; 
extraperitoneal,  136;  transperitoneal, 
135. 

Ligature  of  the  innominate  artery,  158. 
161;  Ballance  and  Edmunds  stay  knot 
in,  162;  Bardenheuer's  method,  161; 
Coopers  method  of,  162;  Curtis's  meth- 
od of,  164;  drainage  in,  168;  fallacies 
in,  167;  general  remarks  on,  167; 
Ivocher's  incision  for,  159;  material 
used  for  ligature  in,  167 ;  Milton's  meth- 
od, 164;  Mott's  incision  for,  158;  num- 
ber of  ligatui'es  in,  167;  results,  168; 
splitting  the  manubrium  in,  163 ;  with 
resection  of  sterno-clavicular  articula- 
tion and  upper  end  of  sternum,  Bur- 
rell's,  160;  with  stay  knot,  84. 

Ligature  of  internal  mammary  artery, 
177. 

Ligature  of  jugular  vein,  external,  215; 
internal,  lateral,  215;  internal,  results, 
215. 

Ligature  of  lingual  artery,  197;  at  apex 
of  greater  cornu,  198;  at  point  of  elec- 
tion, 199;  between  greater  cornu  and 
posterior  belly  of  digastric,  198;  in  tri- 
angle made  by  the  digastric  and  mylo- 
hyoid muscles  and  hypoglossal  nerves, 
199;  results,  200;  three  situations  for, 
198. 

Ligature  of  meningocele,  230. 

Ligature  of  middle  meningeal  artery,  214. 

Ligature  of  occipital  artery,  201 ;  at  ori- 
gin, 202;   behind  mastoid  process,  202. 

Ligature  of  palmar  arches,  190. 

Ligature  of  peroneal  artery,  155 ;  fallacies 
of,  158. 

Ligature  of  popliteal  artery,  149;  lower 
third,  150;  middle  third,  149;  upper 
third,  150;  results,  150. 

Ligature  of  pudic,  internal,  artery,   137. 

Ligature  of  radial  artery,  185;  at  apex 
of  styloid  process,  187;  fallacies  in, 
188;  lower  third,  187;  results,  188;  up- 
per third,  186. 

Ligature  of  saphenous  vein,  internal,  for 
varicose  veins,  Trendelenburg,  217. 

Ligature  of  sciatic  artery,  136;  fallacies 
of,  137;  results  of,  137. 

Ligature  of  subclavian  artery,  168;  first 
portion,  left  side,  168,  169;  first  portion, 
left  side,  results,  170;  first  portion, 
right  side,  170;  first  portion,  right  side, 
results,  171;  second  portion,  174;  sec- 
ond portion,  results,  174;  third  portion, 
171,   172;  third  portion,  results,  174. 

Ligature  of  subclavian  vein,  lateral,  215. 

Ligature  of  temporal  artery,  201. 

Ligature  of  thyroid  artery,  inferior,  177, 
178;  inferior,  fallacies  and  results  of, 
178;  superior,  197. 

Ligature  of  tibial  artery,  anterior,  1^0; 
fallacies  of,  152;  lower  third,  152;  mid- 
dle third,  151;  upper  third,  151. 

Ligature  of  tibial  artery,  posterior,  153; 
between  os  calcis  and  internal  malleo- 


INDEX. 


XXI 


lus,  155;  fallacies,  155;  lower  third, 
154;  middle  third,  154. 

Ligature  of  ulnar  artery,  188;  at  junction 
of  upper  and  middle  thirds,  189;  at 
wrist,  189;  fallacies,  189;  lower  third, 
189;  results,  190. 

Ligature  of  varicose  veins,  subcutaneous, 
21(3;  needle  for,  217;  precautions  in, 
217;  results  of,  217. 

Ligature  of  veins,  215;  at  extremities, 
215;  in  continuity,  215;  materials  for, 
215. 

Ligature  of  vertebral  artery,  174;  before 
entering  vertebral  canal,  175;  between 
atlas  and  axis,  176;  between  atlas  and 
occipital  bone,  177;  fallacy,  177;  re- 
sults, 177. 

Ligature,  selection  of  vessel  for,  126. 

Ligatures,  129;  as  htemostatics,  81;  cat- 
gut, 86;  force  necessary  to  tie,  81; 
Grad's  method  of  loosening,  85 :  mate- 
rials for,  85;  method  of  application  of, 
82;  of  aortic  tissue,  93;  of  whalebone 
tissue,  93;  silk,  85;  size  of,  81. 

Ligaturing,  subcutaneous,  of  a  nrevus,  224. 

Lignerolles's  subastragaloid  amputation, 
507. 

Linear  craniotomy  for  microcephalus, 
241 ;  dangers  of,  244 :  forms  of  bone  in- 
cision in,  242 ;  removal  of  areas  of  bone 
in,  243;  results  of,  244;  the  operation 
of,  242. 

Linear  guide  to  abdominal  aorta,  130, 
131;  to  an  artery,  125;  to  axillary  ar- 
tery, first  portion,  178;  to  axillary 
artery,  third  portion,  179;  to  brachial 
artery,  181;  to  carotid  artery,  common, 
191 ;  to  carotid  artery,  external,  195 ; 
to  carotid  artery,  internal,  196,  197 ;  to 
dorsalis  pedis  artery,  153 ;  to  epigastric 
artery,  deep,  141 ;  to  femoral  artery, 
143;  to'  gluteal  artery,  136;  to  iliac 
artery,  132 ;  to  iliac  artery,  common, 
133;  to  iliac  artery,  external,  138:  to 
iliac  artery,  internal,  135 ;  to  innomi- 
nate artery,  158;  to  internal  mam- 
mary artery,  177 ;  to  lingual  artery, 
198;  to  palmar  arches.  190:  to  peroneal 
artery,  155 ;  to  popliteal  artery,  149 :  to 
pudic  artery,  internal,  138 ;  to  radial 
artery,  186;  to  sciatic  artery,  137;  to 
subclavian  artery,  second  portion,  174; 
to  subclavian  artery,  third  portion, 
171;  to  thyroid  artery,  inferior,  177; 
to  tibial  artery,  antei-ior,  151 ;  to  tibial 
artery,  posterior,  154;  to  ulnar  artery, 
188;  to  vertebral  artery,  175. 

Linear  osteotomy,  433. 

Linear  semilunaris  as  a  guide  to  the  iliac 
artery,  132. 

Lingual  artery,  anatomical  points  of.  197, 
199;  guides' to,  198:  ligature  of,  197. 

Lingual  nerve  (gustatory),  2SS;  anatom- 
ical points  of,  288 ;  extrabuccal  opera- 
tion on,  289 ;  guides  to,  289 :  intrabuc- 
cal  operation  on,  289;  routes  to,  289. 


Lion-jawed  forceps,  Fergusson's,  465. 

Lip,  lower,  eheiioplasty  of,  605;  Blasius's 
method,  606;  liruns's  metliod,  608; 
Buck's  method,  609;  Celsus's  method, 
607;  Dowds  method,  611;  Estlander's 
method,  607;  Grant's  method,  606; 
horizontal  incision  method,  606;  J^an- 
genbeck's  chin-llap  method,  609 ;  Lan- 
genbeck's  circular-method,  608;  Sedil- 
lot"s  method,  611;  Syme-Buchanan 
method,  609;  tSyme's  method,  609; 
'■  V  "-incision  metliod,  605 ;  Malgaigne's 
method,  610. 

Lip,  upper,  deformities  of,  612. 

Lip,  upper,  eheiioplasty  of,  612;  Bruns's 
method  of,  612;  Buck's  intero-lateral- 
flap  method,  612;  Buck's  semicircular 
vertical-flap  method,  613;  Dieffenback's 
curved-flap  method,  014;  Dieftenbacli's 
"  S  "-shaped-flap  method,  614;  for  en- 
tire loss  of  upper  lip,  613;  Ledran-Mac- 
kenzie  method,  615;  Sedillot's  vertical- 
flap  method,  613;  Szymanowski's  meth- 
od, 614. 

Lisfranc's  amputation  at  the  tarso-meta- 
tarsal  joints,  502. 

Lister's  complete  subperiosteal  excision 
of  Avrist  joint,  404;  modification  of 
Garden's  amputation  of  thigh  through 
condyles,  528;  rule  for  length  of  ampu- 
tation flaps.  458 ;  tourniquet  for  com- 
pressing abdominal  aorta,  541. 

Liston's  bone-cutting  forceps,  465;  for- 
ceps, 77 ;  semilunar  Hap,  method  of  am- 
putation, 456;  incision  for  complete 
excision  of  ujaper  jaw,  368. 

Littenneur's  method  of  flap  transfer  in 
plastic  surgery,  573. 

Lizar's  outer  incision  for  complete  exci- 
sion of  the  upper  jaw,  367. 

Lloyd's  method  of  controlling  bsemor- 
rhage  in  amputation  at  the  hip  joint, 
545. 

Local  anppsthesia,  36;  Gonka's  method  of, 
40;  indications  for,  40. 

Local  anresthetics,  36;  Beta  eucain,  43; 
chloride  of  ethyl,  36;  cocain,  37;  ether, 
30;  eucain,  43:  ice,  30:  introduction 
into  skin  of  sterilized  fluids,  36;  tropo- 
cocain,  40. 

Longitudinal  fissure   (brain),  248. 

Loops,  traction,  129,  130. 

Lorenz's  operation  for  congenital  dis- 
placement of  hip,  440;  remarks  on, 
440:  results  of,  440. 

Losscn's  operation  on  second  portion  of 
trifacial  nerve,  284. 

Lower  extremities,  excisions  of,  407. 

Lower  extremity,  duty  of  surgeon  in  am- 
putations at,  496. 

Lower  jaw,  excision  of,  373 ;  excision  of 
condvle  of,  378 ;  phosphoric  necrosis  of, 
374.  ' 

Liicke's  incision  for  inferior  dental  nerve, 
287 :  operation  on  second  division  of 
trifacial  nerve,  284. 


XXll 


INDEX. 


Ludwig's  angina,  725. 

Lumbar  plexus,  operations  on,  327. 

Lumbar  puncture  for  acute  hydroceph- 
alus, 229. 

Lund's  enucleation  of  astragalus  for  club- 
foot, 449. 

Lungs,  examination  after  operation,  US. 

Lvisk's  (Z.  J.)  method  of  skin-grafting, 
577. 

Lymphatic  glands,  cervical.  Hartley's  op- 
eration on,  730;  incisions  for  removal 
of,  728;  Johns  Hopkins  Hospital  oper- 
ation on,  Mitchell,  731;  results  of  re- 
moval of,  733;  removal  of,  727;  treat- 
ment after  removal  of,  733;  Treves's 
ojjeration  on,  729. 

MacCormac's  method  of  excision  of  scap- 
ula, 382;  method  of  treating  displace- 
ment of  the  ulnar  nerve,  324 ;  posterior 
incision  for  excision  of  upper  end  of 
humerus,  386. 

Macewen's  operation  for  brain  tumor, 
254;  supracondyloid  osteotomy  for  genu 
valgum,  443. 

Mackenzie's  method  of  cheiloplasty  of  up- 
per lip,  615  ;  non-subperiosteal  excision 
of  knee  joint,  418;  tonsillotome,  633. 

Malaria,  6. 

Malgaigne's  double-flap  operation  for 
single  harelip,  600;  method  of  cheilo- 
plasty for  lower  lip,  610;  single-flap 
method  of  amputation  at  the  hip,  555. 

Malignant  disease,  removal  of  associated 
structures  in,  377. 

Malignant  grovs^th  of  clavicle,  operation 
for,  380. 

Mallet  finger,  562. 

Mallet  for  osteotomy,  435. 

Manec's  long  anterior-  and  short  poste- 
rior-flap method  of  hip  amputation,  551. 

Martin's  bandage,  70;  operation  for  de- 
formity of  nose,  593;  platinum  sujDport 
for  deformities  of  nose,  592. 

Mastoid  antrum,  opening  of,  262;  opera- 
tion of  opening,  264;  precautions  for 
operation  of  opening,  265;  results  of 
operation  fcr  opening,  265. 

Mastoid  cells,  264. 

Mastoid  process,  in  the  adult,  262;  in  the 
infant,  262. 

Matas's  infiltration  anaesthesia  apparatus, 
39;  method  of  radical  cure  of  aneurism, 
207;  operation  on  aneurism,  stages  of, 
202. 

Materials  necessary  for  treatment  of  op- 
eration wounds,  96. 

Mathieu's  tonsillotome,  633. 

Mattress,  Crile's  hot  water,  55. 

Maxilla  inferior,  immobility  of,  377. 

Maxillfe,  superior,  simultaneous  removal 
of,  372. 

McBurney's  hook  in  dislocation  and  frac- 
ture of  humerus,  392 ;  method  of  con- 
..  trolling  haemorrhage  in  amputation  at 
hip  joint,  545;  tension  hooks,  576. 


Meckel's  ganglion,  278. 

Median  nerve,  relation  of,  to  brachial  ar- 
tery, 183;  situations  for  exposure  of, 
324. 

Medicated  cotton,  108. 

Medio-tarsal  joint,  amputation,  Cho- 
part's,  504;  Forbes's  modification  of 
Chopart's,  505;  remarks  on  and  results 
of  Chopart's,  505. 

Melon-seed  concretions  of  thecitis,  354. 

Meloplasty,  616;  Gersuny's  method,  618; 
Gussenbauer's  method,  617;  Israel's 
method,  617;  Kraske's  method,  618; 
Lallemand's  method,  618;  remarks  on, 
618;  Trendelenburg's  method,  617. 

Meningeal  artery,  middle,  237 ;  ligature 
of,  214. 

Meningeal  drainage,  spinal,   316. 

Meningeal  hfemorrhage,  craniotomy  for, 
238. 

Meningitis  after  craniotomy,  244. 

Meningocele,  229;  excision  of,  230,  318; 
injection  of,  230;  ligature  of,  230;  oper- 
ative measures  for,  229;  puncture  and 
tapping  of,  230. 

Meningo-myelocele,  result  of  operation  on, 
319;    treatment  of,   318. 

Mercury  biniodide,  solutions  of,  60. 

Metacarpal  bones,  amputation  of  four, 
with  fingers,  476;  of  inner  three,  476; 
of  last  four,  475;  of  last  two,  476; 
through,  475. 

Metacarpo-phalangeal  articulation,  ampu- 
tation at,  471 ;  by  lateral-fiap  method, 
472;  by  oval-flap  method,  471;  of  sec- 
ond and  third  fingers,  471. 

Metacarpo-phalangeal  joints,  excision  of, 
407. 

Metallic  sutures,  98. 

Metatarsal  bone  of  second,  third  or  fourth 
toe,  amputation  of,  502. 

Metatarsal  bones,  amputation  through, 
500. 

Metatarso-phalangeal  articulation,  am- 
IDutation  of  all  toes  at,  499;  comments 
on  and  results  of,  500. 

Metatarso-phalangeal  joint,  excision  of, 
408;  of  great  toe,  excision  of,  408. 

Microcephalus,  linear  craniotomy  for,  241. 

Middle  meningeal  artery,  237;  arrest  of 
haemorrhage  from,  237;  Kronlein's 
method  of  locating,  29;  ligature  of, 
214. 

Migratory  flaps  in  plastic  surgery,  571. 

Mikulicz's  method  of  pharyngotomy, 
646;  osteojilastic  resection  of  tarsus, 
415. 

Miller's  method  of  preparing  catgut,  91. 

Milne's  serre-flne  forceps,  78. 

Milton's  method  of  ligature  of  the  innom- 
inate, 164. 

Miner's  elbow,  353. 

Mirault's  single-flap  operation  for  single 
harelip,  600. 

Mitchell's  operation  on  cervical  lymphat- 
ic glands,  731 ;  remarks  on,  732. 


INDEX. 


XXlll 


Mittens,  antiseptic,  114. 

Mixter's  oj^eiation  on  trifacial  nerve  at 
base  of  slcull,  2U3. 

Molliere's  tarsal   amputation,   50G. 

]\Iorbid  processes  of  clavicle,  379. 

Morphin-cocain-chloroform  ana>stliesia,  40. 

Morphine  with  anaesthetics,  35. 

Mortality  in  gunshot  wounds  of  the  cra- 
nium, 270. 

Morton's  metliod  of  inducing  spinal  anaes- 
thesia, 43. 

Moss  dressing,  112. 

"  Mother's  mark,"  223 ;  treatment  of,  223 ; 
by  electrolysis,  224;  by  freezing  and  in- 
cisions, 223 ;  by  heated  needles,  224 ;  by 
injection,  224;  by  I'aquelin  cautery, 
224. 

Motor  center,  removal  of,  for  cure  of  epi- 
lepsy, 257. 

Mott's  incision  for  ligation  of  the  innom- 
inate artery,  158 ;    retractors,  129. 

Mouse-tooth  forceps,  129. 

Mouth,  deformities  of,  015;  operations  on, 
632. 

iMouth  gag,  13,  119;  Denhard's,  285; 
Goodwillie's,  285. 

Movable  immovable  aneurism  needle,  130. 

]Moynihan's  operation  on  spontaneous 
subclavian  aneurism,  203. 

Mucous  bursfie,  353. 

Mucous  surfaces,  preparation  of,  for  oper- 
ation, 95. 

Multifidus  spinse,  myotomy  of,  337. 

Murray's  method  of  ligaturing  abdo- 
minal aorta,  131;  of  preparing  catgut, 
92. 

Muscle,  division  of,  347;  rupture  of, 
348. 

Muscles,  concerned  with  staphylorrhaphy, 
621;  manner  of  dividing,  in  amputation, 
534;  retraction  of  divided,  455;  retrac- 
tion of,  in  amputations  after  removal 
of  Esmarch's  bandage,  533;  rupture  of, 
347. 

Muscular  action,  perverse,  as  a  cause  of 
deformities,  561. 

Muscular  guide  to  an  artery,  125;  to  ax- 
illary artery,  first  portion,  178;  to  axil- 
lary artery,  third  portion,  180;  to  bra- 
chial artery,  181 ;  to  carotid  artery, 
common,  191;  to  carotid  artery,  exter- 
nal, 195;  to  carotid  artery,  internal, 
196;  to  dorsalis  pedis  artery,  153;  to 
iliac  artery,  internal,  135;  to  facial 
artery,  200;  to  femoral  artery,  143;  to 
popliteal  artery,  149;  to  radial  artery, 
186;  to  sciatic  artery,  137;  to  subcla- 
vian artery,  first  portion,  168,  170:  to 
subclavian  artery,  second  portion,  171, 
174;  to  subclavian  artery,  third  por- 
tion, 171 ;  to  tibial  artery,  anterior, 
151;  to  tibial  artery,  posterior,  154;  to 
ulnar  artery,  188 ;  to  vertebral  arterv, 
175. 

Muscular  guides  to  subclavian  artery, 
168. 


Muscular  influence  in  staphylorrhaphy, 
621. 

Musculo-cutaneous  amputation  flaps,  452. 

Musculo-eutaneous  nerve,  situations  for 
exposure  of,  322;  operations  on,  322. 

Musculo-spinal  nerve,  operations  on, 
322. 

Muslin  as  a  dressing,  112. 

Mustard  sinapisms  during  shock,  121. 

JMyotome,    337,    347. 

Myotomy,  337,  347;  oblique,  347;  of  del- 
toid, 348 ;  of  erector  spines,  338 ;  of 
latissimus  dorsi,  338;  of  multifidus 
spina?,  337 ;  of  pectineus,  337 ;  of  pec- 
toralis  major,  348;  of  sterno-cleido 
mastoid,  338;  of  tensor  vaginae  femoris, 
337;  of  trapezius,  338;  "  V  "-shaped, 
347. 

JS'fevus,  treatment  of,  by  ligature,  double, 
224,  225;  by  ligature,  single,  224;  by 
ligature,  subcutaneous,  224;  with  se- 
tons  in,  225. 

Nail,  toe,  ingrown,  operations  for,  567; 
Anger's,  567;  Cotting's,  568;  results  of, 
568. 

Nails,  preparation  of  the,  for  an  opera- 
tion,   113. 

Naphthalin,   110. 

Nares,  plugging  of  posterioi",  650. 

Nasal  and  naso-pharj^ngeal  polypi,  oper- 
ation for,  Annandale's,  657;  Boeckel's, 
657;  Chalot's,  656;  Chassaignac's,  654; 
Cheever's,  659;  choice  of,  for  removal 
of,  661;  Desprez's,  653;  general  com- 
ments on,  659;  Guerin's,  659;  instru- 
ments for,  653;  Kocher's,  659;  Langen- 
beck's,  maxillary  route,  657 ;  Langen- 
beck's,  maxillary  route,  comments  on, 
658 ;  Langenbeck's,  nasal  route,  655 ; 
Lawrences,  655 ;  nasal  route,  653 ;  na- 
sal route,  comments  on,  655 ;  Nelaton's, 
656;  Ollier's,  654;  palatine  route,  656; 
llouge's,  654,  655;  results,  661;  treat- 
ment after,  661. 

Nasal  growths,  operations  for,  vide  Nasal 
and  Naso-pliaryngeal  Polvpi,  operations 
for. 

Nasal  polypi,  removal  of,  with  forceps  or 
snare,  651. 

Nasal  septum,  deviation  of.  601 :  devia- 
tion of,  Post's  operation  for,  662 ;  devia- 
tion of,  Wagner's  operation  for,  662. 

Nasal  splints,  662. 

Naso-lnmbdoidnl  lino,  Poirier's,  250. 

Naso-pharyngeal  polypi,  removal  of,  653. 

Natural  lurmostatics,  65. 

Neck,  abscess  and  phlegmon  of.  725;  ex- 
cision of  diseased  lymphatic  glands  of, 
727:  operations  on,  681:  treatment  of 
wounds  of,  724;  wounds  of.  723. 

Necrosis,  of  bone,  350;  phosphoric,  of 
lower  jaw,  374. 

Needle,  aneurism.  129;  Fletcher's,  130:  in 
ligature  of  arteries,  127;  inovable  im- 
uiovable,   130;  student's,  130. 


XXIV 


INDEX. 


Needle,  aneurismal,  in  amputating, 
467. 

Needle,  forceps  oi'  holders,  99. 

Needle,  for  subcutaneous  ligaturing  of 
varicose  veins,  217. 

Needle,  heated,  for  treatment  of  birth- 
mark, 224. 

Needle,  surgical,  76. 

Needle,  Wyeth's,  in  shoulder-joint  ampu- 
tation, 487. 

Needles,  98. 

Nelaton's  operation  for  removal  of  nasal 
growths,  656. 

Neoplasms  of  the  nose,  operations  for, 
vide  Nasal  and  Naso-pharyngeal 
Polypi. 

Nephritis  after  anaesthesia,  21. 

Nerve,  auriculo-temporal,  289 ;  auricula- 
ris  niagnus,  operation  on,  320 ;  avul- 
sion, 272 ;  buccal,  exposure  of,  290 ;  cir- 
cumflex, operations  on,  323 ;  crural, 
anterior,  operation  on,  327 ;  dental,  an- 
terior division  of,  278;  dental  infe- 
rior, 284;  facial  exposure  of,  307;  fifth, 
supramaxillary  division  of,  277 ;  glu- 
teal, exposure  of,  324;  inclusion  of, 
in      ligature,      82;      infraorbital,      op- 

I  erations  on,  277;  laryngeal,  recurrent, 
dangers  to,  in  operations  on  thyroid, 
722;  lingual  or  gustatory,  288;  median 
exposure  of,  324;  musculo-cutaneous, 
situations  for  exposure  of,  322 ;  musculo- 
spiral,  operations  on,  322;  obturator, 
exposure  of,  327;  occipitalis  major,  320; 
perineal,  exposure  of,  327;  popliteal, 
external,  method  of  reaching,  326; 
popliteal,  internal,  method  of  reaching, 
326;  pudic,  exposure  of,  324;  radial  ex- 
posure of,  324;  resection,  271;  saphe- 
nous, external  or  short,  exposure  of, 
328 ;  saphenous,  internal  or  long,  expo- 
sure of,  328;  section,  271 ;  sciatic,  great 
exposure  of,  324;  sciatic,  small,  expo- 
sure of,  324;  spinal  accessory,  operation 
on,  319;  stretching,  dry,  272;  submax- 
illary, 279;  suboccipital,  320;  superior 
maxillary,  278;  supraorbital,  opera- 
tions on,  276;  supratrochlear,  opera- 
tions on,  277;  suture,  272;  suture, 
Gleiss's  method,  274;  suture,  primary, 
273;  suture,  results,  274;  suture,  sec- 
ondary, 273;  tibial,  anterior,  exposure 
of,  327;  tibial,  posterior,  exposure  of, 
327;  trifacial,  first  division  of,  opera- 
tions on,  276;  trifacial,  second  divi- 
sion of,  operations  on,  277;  trifacial, 
third  division  of,  operations  on,  284; 
ulnar,  exposure  of,  324 ;  ulnar,  displace- 
ment of,  324. 

Nerves,  cervical,  operations  on  branches 
of,  320;  facial,  in  opening  the  mastoid 
antrum,  264;  operations  on  special, 
276;  plantar,  exposure  of,  327;  recur- 
rent laryngeal,  efi'ect  of  division  of, 
730;  resection  of  spinal  accessory  and 
posterior  divisions  of  cervical,  for  wry- 


neck, 562;  severing  of,  in  amputations, 
452;  spinal,  intraspinal  division  of,  321; 
spinal,  operations  on,  311;  special  op- 
erations on,  271;  tibial,  anterior  and 
posterior,  exposure  of,  327. 

Nervous  guides  to  an  artery,  125. 

Nervous  system,  operations  on,  227. 

Neuber's  decalcified  tubes  for  drainage, 
106;  method  of  drainage  by  canaliza- 
tion, 107;  method  of  healing  bony  de- 
fects by  canalization,  358. 

Neurectomy,  intracranial  of  trifacial, 
295. 

Neuroplasty,  274;  Duncan's  method,  275. 

Nicoladoni's  method  of  tendon  suturing, 
340. 

Nitrite  of  amyl,  119. 

Nitrous  oxide,  32;  danger  of,  17;  with 
oxygen,  33. 

Noma,  616. 

Non-encapsulated  brain  tumor,  treatment 
of,  254. 

Norton's  operation  for  webbed  fingers, 
564. 

Nose,  angular,  595;  deformities  of,  angu- 
lar, 592;  deformities  of,  comments  on, 
593;  deformities  of,  injection  of  paraffin 
for,  593;  deformities  of,  Martin's  opera- 
tion for,  593;  deformities  of,  platinum 
support  for,  592;  deformities  of,  saddle- 
back, 592;  deformities  of,  supjjorts 
for,  593;  disfigurement  of,  dependent 
on  morbid  growths,  596;  operations  on, 
650. 

Nursing,  9. 

Oakum  cushion  after  operation,  118. 

Obturator  nerve,  exposure  of,  327. 

Occipital  artery,  anatomical  j^oints  of, 
201;  ligature  of,  201. 

Occipitalis  major  nerve,  operation  on, 
320. 

Ochsner's  method  of  treating  stricture  of 
the  oesophagus,  674. 

O'Dwyer's  apparatus  for  intubation  of  lar- 
nyx,  694. 

CEsophageal  bougie,  664;  bougie,  conical, 
Knott's,  674;  probang,  664. 

CEsophagectomy,  678;  results  of,  678. 

Oilsophagostomy,  678. 

CEsophagotomy,  668;  cervical,  668;  cer- 
vical, fallacies  of,  669;  cervical,  re- 
marks on,  669  ;  cervical,  results  of,  670 ; 
external,  674;  internal,  674;  instru- 
ments for  internal,  674;  results  of  in- 
ternal, 675. 

oesophagus,  diverticula  of,  678;  Girard's 
operation  for,  681;  operation  for,  679; 
results  of  operation  on,  681;  treatment 
after  operation  on,  681. 

(Esophagus,  foreign  bodies  in,  663,  667; 
intrathoracic  portion  of,  670. 

CEsophagus,  introduction  of  instruments 
into,  665;  precautions  in  and  remai'ks 
on,  666. 

CEsophagus,  methods  of  entering,  668, 


INDEX. 


XXV 


Q^sophajxiis,  operations  on,  663;  anatom- 
ical points  for,  ()()3. 

Gilriophugus,  stricture  of,  672 ;  Abbe's  op- 
eration for,  675 ;  author's  operation 
for,  676;  comments  on  operations  for, 
676;  dilatation  of,  672;  divuision  of, 
674;  division  of,  by  string  fiiction,  675; 
external  o^sopliagotomy  for,  674;  inter- 
nal oesophagotomy  for,  674;  malignant. 
677;  results  after  operations  for,  677; 
results  of  tubage  in.  67S  ;  treatment  aft- 
er operations  for,  677;  tubage  in.  677. 

CEsophagus,  surgical  relations  of,  668. 

Ogston"s  excision  of  astragalo-seaphoid 
joint  for  relief  of  talipes,  449;  osteo- 
arthrotomy for  genu  valgum.  443. 

Oil  of  camphor  during  shock,  121. 

Oiled  silk  as  a  dressing,  107. 

Oils,  essential,  62. 

Oilier 's  excision  of  knee  joint,  subperios- 
teal, 421:  excision  of  humerus,  upper 
end,  oblique  incision,  385 :  excision  of 
scapula,  subperiosteal,  383;  excision  of 
wrist  joint,  complete,  subperiosteal, 
403;  operation  for  removal  of  nasal 
and  naso-pharyngeal  polypi,  654;  oper- 
ation of  osteoplastic  rhinoplasty.  590. 

Oozing,   from   operation-wounds.   96. 

Open  dressing,  after  operation,  118. 

Operating  cases  and  bags,  45. 

Operating-room,   temperature    of,    130. 

Operating  table.  53,  113;  characteristics 
of  a  good,  54;  Cleveland's,  54;  Ede- 
bohls's,  56;  extemporized,  53;  Fowler"s, 
55;  inclined  plane  for  use  in  conjunc- 
tion with,  56:  portable,  56;  Pryor's,  56; 
preparation  of,  53. 

Operation,  disposition  of  assistants  at, 
93;  care  of  patient  after,  118;  change 
of  dressings  after,  118:  consent  of  pa- 
tient to,  6;  emergencies  during,  special, 
120;  number  of  assistants  necessary  for, 
93;  nurse  at,  94;  place  for,  7;  prepara- 
tion for,  general  remarks  on,  95;  prepa- 
ration for,  of  septic  parts,  95;  prepara- 
tion for,  summary,  113;  preparation  of 
field  of,  94 :  pi'eparation  of  mucous  sur- 
faces for,  95  :  preparation  of  patient  for, 
94;  preparatorjr  treatment  for,  7;  rela- 
tion of,  shock  to,  120:  rehearsal  of 
steps  of,  by  surgeon,  119;  relation  of 
things  necessary  to,  93 ;  requirements 
for,  essential,  9:  requirements  for.  pre- 
cautionary, 119:  time  for,  7. 

Operations,  after  reaction  from  shock, 
4:  complications  of,  5:  cosmetic  effects 
of,  2:  diet  after,  9:  during  shock,  4: 
facts  to  be  considered  prior  to,  2.  6:  in 
old  age,  2;  in  youth.  2:  instruments 
necessary  for,  44 ;  nursing  after,  9 :  on 
alcoholics,  6;  on  arteries,  special,  202; 
on  athletics,  3;  on  bones,  356;  on  dia- 
betics, 5;  on  genito-urinary  organs,  an- 
cesthesia  in,  16:  on  ha^'mophiliacs.  6; 
on  moiith.  anfpsthesia  in.  16:  on  nerv- 
ous system,  227;   on  obese,  3;   on  ple- 


thoric, 3:  on  rectum,  anaesthesia  in, 
16;  on  .semi-invalids,  3;  on  tendons, 
ligaments,  fascias,  muscles  and  bursae, 
329;  on  veins  and  capillaries,  215;  on 
women,  3;  preparation  of  room  for,  8; 
requirements,  relating  to,  essential,  9; 
requirements,  relating  to,  precaution- 
ary, 9;  risks  of,  2;  supervention  of 
shock  during,  4. 

Operation-wound,  drainage  of,  104;  dress- 
ing of,  107:  treatment  of,  96. 

Operative  propriety,  10. 

Operative  surgery,  general  considerations 
of,  1. 

Operator,  preparation  of,  113. 

Oral  screw,  14. 

Organic    ligatures.    81 ;    sutures,   97. 

Ormsby"s  inhaler,  27. 

Os  calcis,  amputation  through,  Tripier's, 
508. 

Ossification,  periods  of,  in  calcaneum,  im- 
portance of  a  knowledge  of,  408. 

Osteo-arthrotomy  for  genu  valgum, 
Chiene's,  444;  Osston's,  443;  Reeves's, 
443;  results,  444.'' 

Osteoplastic  amputation  of  leg.  Bier's 
and  Eiselsberg's,  530. 

Osteoplastic  amputation  of  thigh,  Grit- 
ti"s  method,  529:  results,  530;  Sabane- 
jefi'"s  method,  532;  Stokes's  modifica- 
tion of  Gritti's  method,  529. 

Osteoplastic  flaps,  530:  in  laminectomy, 
315;  in  uranoplasty,  625. 

Osteoplastic  rhinoplasty,  590;  Israel's 
modification  of  Konig's  operation.  591 ; 
Konig's  operation.  591 ;  OUier's  opera- 
tion, 590 :  Pancoast's  subcutaneous, 
592. 

Osteoplastic  resection  of  tarsus,  \Yladi- 
mirow-Mikulicz  method,  415;  results, 
416. 

Osteoplasty,  450. 

Osteotome.  435. 

Osteotomy,  432 ;  comments  on  operation 
of.  435 ;  methods  of,  433 ;  instruments 
for.  433. 

Osteotomy  at  neck  of  femur.  Volk- 
niann's.  437;  \'olkmann's.  results,  438; 
with  osteotome.  437:  with  osteotome, 
remarks  on.  437. 

Osteotomy,  cuneiform,  for  bony  anchy- 
losis of  knee,  441 ;  for  bony  anchylosis 
of  knee.  Barton's.  441 :  for  genu  varum, 
446:  for  relief  of  talipes.  Bird's,  449; 
for  relief  of  talipes,  Stokes's,  449 ;  inter- 
trochanteric, of  femur,  Volkmann's, 
438:  intertrochanteric  of  femur,  re- 
sults, 438;  of  tarsus  for  talipes  equino- 
varus,  Davies-Colly,  447 :  of  tarsus  for 
talipes  equiro-varus,  results.  448, 

Osteotomy  for  anchylosis  of  knee,  gen- 
eral remarks  on.  442. 

Osteotomy  for  genu  varum.  444:  of  tibia, 
445;  results,  445,  446;  treatment  after, 
446. 

Osteotomy  for  talipes,  447. 


XXVI 


INDEX. 


Osteotomy,  intertrochanteric,  of  femur, 
Sayre's  modification  of  Barton's,  438; 
results,  438. 

Osteotomy,  linear,  for  bony  "anchylosis 
at  knee,  441;  for  genu  varum,  445; 
of  neck  of  astragalus  for  talipes  equino- 
varus,  Bradford's,  448;  of  neck  of 
astragalus  for  talipes  equino-varus, 
results,  448. 

Osteotomy  of  femur,  intertrochanteric, 
438;  shaft  of,  Gant's,  438;  shaft  of,  re- 
marks on,  439;  neck  of,  subcutaneous, 
Adams's,  436;  neck  of,  subcutaneous, 
remarks  and  results,  437 ;  supracondy- 
loid,  for  genu  valgum,  Macewen's,  443; 
supracondyloid  for  genu  valgum,  re- 
sults, 443;   treatment  after,  439. 

Otitis  media,  as  a  cause  of  cerebral  ab- 
scess, 258. 

Owen's  operation  for  complicated  double 
harelip,  605. 

Oxalic  acid  in  cleansing  the  hands,  114. 

Oxygen,  administration  of,  during  anaes- 
thesia, 35;  during  shock,  121. 

Packing  after  removal  of  brain  tumor, 
254. 

Pads,  of  aseptic  gauze,  63 ;  use  of,  in 
serous  cavities,  64. 

Pain,  due  to  inclusion  of  nerve  in  liga- 
ture, 82. 

Palate,  closure  of  opening  in,  by  mechan- 
ical means,  630;  hard,  fissure  in,  623; 
soft,  abnormal  opening  in,  620;  opera- 
tions on,  618;  operations  on,  instru- 
ments for,  620. 

Pallor  during  shock;,  121. 

Palmar  arches,  ligature  of,  190;  linear 
guide,  190;  precautions  in  ligature  of, 
191 ;  relations  of,  190. 

Palmar  fascia,  350. 

Pancoast's  operation  on  the  trifacial 
nerve  at  foramen  ovale,  293;  subcu- 
taneous operation  of  osteoplastic  rhino- 
plasty, 592;  tourniquet  for  compressing 
abdominal  aorta,  541. 

Paquelin  cautery,  79;  in  treatment  of 
birthmark,  224. 

Paraffin,  injection  of,  for  nasal  deformi- 
ties, 593;  dangers  of,  595;  remarks  on, 
and  results  of,  595. 

Paralysis,  facial,  extra  cerebral  origin, 
operation  for,  310;  general,  of  thein- 
sane,  craniotomy  for,  261. 

Paraneural  infiltration  anesthesia,  re- 
gional, 38. 

Paravicini's  operation  on  inferior  dental 
nerve,  285. 

Parieto-occipital  fissure,  248. 

Parker's  retractors,  129. 

Parkin's  operation  of  tapping  subarach- 
noid space,  316;  results  of,  316. 

Parotid  gland,  anatomical  points  of,  734; 
extirpation  of,  734;  contraindications 
to  extirpation  of,  735;  results  of  extir- 
pation of,  737, 


Patella,  excision  of,  425;  precautions  in 
excision  of,  425;  removal  of,  in  excision 
of  knee  joint,  424;  results  of  excision 
of,  425. 

Patient,  care  of,  after  anaesthesia,  21; 
care  of,  after  operation,  118;  consider- 
ations relating  to,  prior  to  operation, 
2,  6;  control  of,  during  operation  for 
harelip,  596;  coughing  and  swallowing 
of,  under  anaesthesia,  12 ;  effects  of  iodo- 
form upon,  112;  giving  fluids  to  an  un- 
conscious, 119;  method  of  restraint  of, 
under  anaesthetic,  11;  position  of,  for 
staphylorrhaphy,  620;  preparation  of, 
for  craniotomy,  250;  preparation  of,  for 
plastic  surgery,  569 ;  preparation  of,  for 
operation,  94,  113;  preparation  of,  for 
operations  on  tongue,  635 ;  relation  of, 
to  anaesthetist,  15;  struggling  of,  under 
anaesthetic,  11. 

Peat  dressing,  112. 

Pectineus,  myotomy  of,  337. 

Pectoralis  major,  myotomy  of,  348. 

Pedicles,  removal  of  ligatures  from,  Grad, 
85. 

Perier's  method  of  laryngectomy,  706. 

Perineal  nerve,  exposure  of,  327. 

Periosteal  elevator,  465. 

Periosteal  Hap,  amputation,  452. 

Periosteum  in  young  subjects,  377;  pres- 
ervation of,  522;  treatment  of,  in  am- 
putations, 452. 

Pei'manganate  of  potash  in  cleansing  the 
hands,  114. 

Peroneal  artery,  anatomical  points  of, 
155;  ligature  of,  155;  linear  guide  to, 
155. 

Peroneus  brevis,  tenotomy  of,  334 ;  longus, 
tenotomy  of,  334;  tertius,  tenotomy  of, 
335. 

Peroxide  of  hydrogen,  61;  in  septic  cases, 
95. 

Petit's  tourniquet,  72. 

Petrous  portion  of  temporal  bone  in  cere- 
bral abscess,  260. 

Phalangeal  articulations,  hand,  amputa- 
tions at,  469 ;  anatomical  points  for  am- 
putation at,  469;  remarks  on  amputa- 
tions at,  470. 

Phalangeal  joints,  excision  of,  407;  of  tar- 
sus, excision  of,  407. 

Phalanges  of  toes,  amputation  of,  496. 

Phalanx,  finger,  terminal,  amputation  of, 
469. 

Pharyngotomy,  Cheever's  method,  645; 
Czerny's  method,  646;  general  remarks 
on,  646;  low  latei'al,  647;  low  lateral, 
remarks  on,  649;  low  latei'al  results  of, 
650 ;  Mikulicz's  method,  646 ;  results  of, 
647;  subhyoid,  692;  subhyoid,  progno- 
sis in,  693 ;  treatment  after,  647. 

Phelps's  open  incision  for  talipes  equino- 
varus,  448 ;  results  of,  449. 

Phlebectasy,  215. 

Phleborrhaphy,  214. 

Phlegmon  of  neck,  725. 


INDEX. 


xxvn 


Phosphoric  necrosis  of  lower  jaw,  374. 

Pia  mater,  division  of,  in  craniotomy  for 
tumor,  2.53;   lucmorrhage  from,  241. 

Pin,  Jiuck's,  7(5;  use  of,  in  securing  chain- 
age  tube,  lOG;   Wyeth's,  75. 

Pin  carrier.  Post's  or  Puck's,  103. 

Pin  suture,  102. 

Pirogoll's  amputation  of  foot,  512. 

Plantar  fasciotomy,  349. 

IMantar  nerves,  exposure  of,  327. 

Plaster-of-Paris  bandage,  after  excision 
of  head  of  humerus,  389;  jacket  for 
curvature  of  spine,  Sayre's,  500. 

Plastic  surgery,  569;  preparation  of  pa- 
tient for,  569;  size  of  flaps  in,  569. 

Plastic  surgery,  transfer  of  flaps  in,  meth- 
ods of,  571;  grafting,  575;  inversion  and 
eversion,  574;  jumping,  574;  sliding  in 
a  curved  line,  572 ;  sliding  in  a  direct 
line,  571;  tagliacotian  method,  574. 

Plethora,  operations  on  the,  3. 

Plexus,  brachial,  operations  on  branches 
of,  321;  lumbar,  operations  on,  327; 
sacral,  exposure  of  branches  of,  324. 

Plugging  of  posterior  nares,  650  ;  remarks 
on,  651. 

Pneumogastric  nerve  during  shock,  120. 

Pneumonia  after  anaesthesia,  21. 

Pocket  cases,  45. 

Poirier's  naso-lambdoidal  line,  250. 

Poisoning,  iodoform,  symptoms  of,  112. 

Pollock's  amputation  at  knee  joint,  long 
anterior-  and  short  posterior-flap  meth- 
od, 527;  method  of  excision  of  scapula, 
382. 

Polydactylism,  563. 

Polypi,  nasal,  removal  of,  with  forceps  or 
snare,  651;  nasopharyngeal,  removal  of, 
653. 

Polypi,  nasal  and  nasopharyngeal,  An- 
nandale's  operation  for,  657 ;  Boeckel's 
operation  for,  657 ;  Chalot's  operation 
for,  656;  Chassaignae's  operation  for, 
654;  Cheever's  operation  for,  559; 
choice  of  operation  for  removal  of,  661 ; 
Desprez's  operation  for,  653;  general 
comments  on  removal  of,  659;  Guerin's 
operation  for,  659 ;  instruments  for  re- 
moval of,  653:  Kocher's  operation  for. 
659 ;  Langenbeck's  operation  for,  max- 
illary route,  657;  Langenbeck's  opera- 
tion for,  maxillary  route,  results  of, 
659;  Langenbeck's  operation  for,  nasal 
route,  655 :  Lawrence's  operation  for. 
655;  maxillary  route  for  removal  of, 
657 ;  nasal  route  for  removal  of.  655  : 
Nelaton's  operation  for,  556;  Ollier's 
operation  for.  654 ;  palatine  route 
for  removal  of,  656;  results  of  oper- 
ation for,  661 ;  Rouge's  operation  for, 
654,  655 ;  treatment  after  removal  of, 
661. 

Popliteal  artery,  anatomical  points  of, 
149;  ligature  of,  149;  ligature  at  mid- 
dle third,  dangers  of,  149 ;  linear  guide 
to,  149;   muscular  guides  to,  149. 


Popliteal  nerve,  external,  method  of 
reaching,  326;  internal,  method  of 
reaching,   .320. 

Position  as  an  hjcmostatic,  68. 

Posterior  nares,  plugging  of,  050. 

Posterior  tibial  artery,  anatomical  points 
of,  153;  ligature  of,  153;  linear  guide 
to,  154;  muscular  guide  to,  154. 

Post-olecranon  bursitis,  treatment  of,  354. 

Post's  operation  for  deviation  of  septum 
nasi,  662 ;   pin   carrier,   103. 

Potassium  permanganate  in  cleansing  the 
hands,   114. 

Powell's  electric  saw,  243. 

Pravaz  syringe,  41. 

Precautionary  requirements  relating  to 
operation,  9,  119. 

Prccentral  fissure    (brain),  249. 

Preparation,  for  operation,  general  re- 
mai-ks  on,  95;  for  operation,  summary 
of,  113;  of  cavity  in  osteoplasty,  450; 
of  catgut,  87 ;  of  field  of  operation, 
94,  113;  of  gauze,  bichloi'ide.  111; 
of  gauze,  iodoform,  110;  of  gauze, 
Thiersch's,  111;  of  hands  for  opera- 
tion, 114;  of  mucous  surfaces  for 
operation,  95;  of  muslin  dressing,  112; 
of  operator  and  assistants  at  operation, 
113;  of  patient  for  craniotomy,  250:  of 
patient  for  operation,  94,  113;  of  a  sep- 
tic part  for  operation,  95;  of  sponges, 
63. 

Prepatellar  bursitis,  treatment  of,  353. 

Pressure,  digital,  as  an  haemostatic,  71; 
instrumental,  as  an  hsemostatic,  72. 

Primary  incision  in  ligature  of  arteries, 
126. 

Primary  suturing  of  nerves,  273. 

Probang,  oesophageal,  664. 

Probe,  129 ;  Fluhrer"s,  267 ;  Girdner's  tele- 
phone, 267 ;  in  ligature  of  arteries,  127 ; 
locating  bullet  with,  after  gunshot 
wounds  of  cranium,  267. 

Professional  reputation,  120. 

Profunda  artery,  ligature  of,  148. 

Protective  dressing,  107. 

Pryor's  operating  table,  56. 

Pudic  artery,  internal,  anatomical  points 
of,  138;  ligature  of,  137. 

Pudic  nerve,  exposure  of,  324. 

Pulsation  as  a  guide  to  an  artery,  125. 
126. 

Pulse  during  anaesthesia,  14,  15 ;  during 
shock,   121. 

Puncture  and  tapping  of  a  meningocele, 
230. 

Pupils,  during  anaesthesia,  15;  during 
chloroform   auiTsthesia,  29. 

Pus,  between  the  dura  and  cranium,  257; 
craniotomy  for  the  evacuation  of,  257 ; 
exploration  of  brain  for,  258. 

Pyaemia  after  craniotomy,  244. 

Pyle's  chisel,  298. 

Quadriceps  extensor,  tenotomy  of,  337. 
Quilled  suture,  102. 


XXVlll 


INDEX. 


Quilt  suture,  Wolfler's,  in  tendon  sutur- 
ing, 340. 

Radial  artery,  anatomical  points  of,  185; 
guides  to,  186;  ligature  of,  185;  points 
for  ligature  of,  186;  pulsation  of,  at 
wrist,   186;   relations  of,  185. 

Radial  nerve,  exposure  of,  324. 

Radius,  excision  of,  399. 

Eanula,  644. 

Receptacles,  for  antiseptic  fluids,  57;  for 
instruments,  51. 

Recurrent  goitre,  720. 

Recurrent  laryngeal  nerve,  effect  of  di- 
vision  of,   730. 

Reef  knot,  83. 

Reeves's  osteo-arthrotomy  for  genu  val- 
gum, 443. 

Reflex  stimulation  during  shock,  120. 

Regnoli's  method  of  removal  of  tongue, 
642. 

Relation  of  arteries  and  veins,  126. 

Relations  of  subclavian  artery,  left  side, 
first  portion,  169. 

Relaxation  and  coaptation  suture,  104. 

Repair  of  cranial  opening  after  circular 
craniotomy,  235. 

Reputation,  professional,  120. 

Requirements  for  operation,  essential,  9; 
precautionary,  9,  119. 

Resection  of  goitre,  Kocher's,  719;  of 
goitre,  remarks  on,  720;  of  nerve,  271; 
of  tarsus,  osteoplastic,  results,  416; 
of  tarsus,  osteoplastic,  Wladimirow- 
Mikulicz,  415. 

Resin  as  a  styptic,  68. 

Respiration,  artificial,  18,  19,  119;  arti- 
ficial, Laborde's  method,  22;  during 
anaesthesia,  14,  15;  rapid,  as  an  anaes- 
thetic, 36. 

Respirations  during  shock,  121. 

Respiratory  force,  impairment  of,  after 
laminectomy,  312. 

Restlessness  during  shock,  121. 

Restraint  of  patients  under  anaesthesia, 
method  of,  11. 

Retentive  coe^ptation  of  wound  surfaces, 
96. 

Retractor,  50,  129;  cloth  in  amputating, 
466;  special  metal,  for  amputations  at 
thigh  and  arm,  466. 

Retroclusion,  76. 

Retropharyngeal  abscess,  726;  Buek- 
hardt's  method  of  opening,  727; 
Chiene's  method  of  opening,  726. 

Reverdin's  method  of  skin-grafting,  575. 

Rhinoplasty,  580;  DieiTenbach's  opera- 
tion, 584 ;  for  loss  of  bony  or  cartilagi- 
nous septum,  with  or  without  loss  of 
nasal  bones,  584;  for  loss  of  columna, 
583 ;  for  loss  of  septum  and  nasal  bones, 
outline  of  flap  in,  588:  for  loss  of  sep- 
tum and  nasal  bones,  treatment  after, 
588;  French  method,  580;  Indian  oper- 
ation, 586;  Italian  operation,  590; 
Keegan's  operation,  589;  Langenbeck's 


operation,  582;  Syme's  operation,  581; 
Weber's  operation,  583;  Verneuil's  op- 
eration, 585. 

Rhinoplasty,  osteoplastic,  590;  Israel's 
modification  of  Konig's,  591;  Konig's 
operation,  591;  Ollier's  operation,  590; 
Pancoast's  subcutaneous,  592. 

Rice  concretions  of  thecitis,  354. 

Rice's  method  of  preparing  catgut,  87; 
method  of  preparing  iodoform  gauze  at 
Bellevue  Hospital,  110. 

Richardson's  operation  for  diverticulum 
of  oesophagus,  679. 

Richelot's  operation  for  salivary  fistula, 
633. 

Rivington's  method  of  ligaturing  the  com- 
mon carotid  artery,  194. 

Rizzoli's  operation  for  immobility  of  in- 
ferior maxilla,  378. 

Rod,  Trendelenburg's,  74. 

Roger's  ligature  or  subclavian  artery, 
left  side,   first  portion,    170. 

Rolando,  location  of  fissure  of,  246;  loca- 
tion of  fissure  of,  by  Chiene's  method, 
247. 

Rose's  method  of  intracranial  neurectomy 
of  trifacial  nerve,  295;  position  for 
staphylorrhaphy,  620. 

Rouge's  operation  for  diseased  bone  and 
naso-pharyngeal  growths,  654,  655. 

Routes  to  lingual  nerve,  289. 

Roux's  amputation  at  ankle  joint,  512. 

Rubber,  dam  as  a  dressing,  107;  finger 
stalls,  115;  rings,  to  control  haemor- 
rhage, 70;  suit,  for  shock  (Crile),  122; 
surgical  cushion,  54;  tissue  as  a  dress- 
ing, 107;  tubing,  for  drainage,  105. 

Rudtlorffer's  operation  for  webbed  fin- 
gers, 564. 

Rugine,  465. 

Ruysch's  method  of  wrist-joint  amputa- 
tion, 478. 

Sabanejefi"'s  osteoplastic  amputation  of 
thigh,  532. 

Sacciform  aneurism,  radical  cure  of,  208. 

Sacral  plexus,  exposure  of  branches  of, 
324. 

Sailer's  method  of  gelatin  injection,  66. 

Saint  Germain's  operation  of  rapid  laryn- 
go-tracheotomy,  689. 

Salicylic  acid,  61. 

Saline  solution,  62;  enemata  of,  222;  in- 
gredients of  (Szumann),  221;  in  shock, 
121;  injection  of,  221;  injection  of,  into 
ventricles,  228;  subcutaneous  injection 
of,  222;  temperature  of,  for  transfusion, 
221. 

Saline  transfusion,  220 ;  Dawbarn's  meth- 
od, 221;  fallacies  of,  222;  during  oper- 
ation,   119. 

Salivary  fistula,  632;  Agnew's  operation 
for,  632;  Desault's  operation  for,  6.32; 
Deguise's  operation  for,  633;  Richelot's 
operation  for,  633;  Van  Buren's  opera- 
tion for,  632. 


INDEX. 


XXIX 


Salzer's  operation  on  trifacial  nerve  at 
foramen  ovale,  293. 

Sand  pillow  for  osteotomy,  43.5. 

Saphenous  nerve,  internal  situations  for 
exposure  of,  32S;  external  exposure  of, 
328. 

Sartorius,  tenotomy  of,  33G. 

Saw,  amputating,  4U4 ;  amputating,  meth- 
od of  iising,  4(J4 ;  chain,  3()4.  4(54 ;  for 
correction  of  deviation  of  nasal  septum, 
6G2 ;  Gigli-Haertel  wire,  243,  3G4,  404 : 
Powell's  electric,  243;  Shrady's,  434; 
Szymanowski's,  419. 

Sawdust  dressing,  112. 

Sayre's  excision  of  hip  joint,  429;  jury- 
mast,  561;  modification  of  Baiton's  in- 
tertrochanteric osteotomy,  438 ;  plaster- 
of-Paris  dressing  for  curvature  of  spine, 
560. 

Scalpels,  129 ;  for  osteotomy,  435 ;  in 
amputating,  463 ;  methods  of  holding, 
45. 

Scapula,  contiguous  anatomy  of,  381;  ex- 
cision of,  381;  excision  of  acromion 
process  of,  382;  excision  of  angles  of, 
383;  excision  of  body  of,  382;  excision 
of,  complete,  381;  excision  of  glenoid 
angle  of,  383;  excision  of,  subperiosteal, 
383. 

Scarpa's  space,  femoral  artery  in,  145. 

Schede's  method  of  healing  bony  defects, 
358;  incision  around  leg  for  varicose 
veins,  218. 

Sehleich's  mixtures  for  general  anaesthe- 
sia, 32 ;  solutions  for  "local  anaesthesia, 
38. 

Schonborn's  operation  of  staphyloplasty, 
630;  results  of,  631. 

Schumpert's  ligature  of  the  subclavian 
artery,  left  side,  first  portion,  170. 

Schwartz's  method  of  resection  of  goitre, 
722. 

Sciatic  artery,  anatomical  points  of,  137 ; 
ligature  of,  136. 

Sciatic  nerve,  great,  bloodless  stretching 
of,  326;  great,  exposure  of,  324,  326; 
great,  fallacy  of  operation  on,  326 ; 
great,  operations  on,  324;  great,  results 
of  operations  on,  326;  small,  exposure 
of,  324. 

Scissors,  48. 

Scurvy,  6. 

Secondary  haemorrhage,  72,  77. 

Secondary  suturing,  101;  of  nerves,  273. 

Section  of  nerve,  271. 

Sedillot's  amputation  of  thigh,  long  an- 
terior-flap method,  537 ;  method  of 
cheiloplasty  of  lower  lip,  611;  method 
of  removal  of  tongue  with  division  of 
jaw,  640 ;  mixed  double-flap  method  of 
amputation,  457 ;  vertical-flap  method 
of  cheiloplasty  of  upper  lip,  613. 

Selection  of  vessel  for  arterial  infusion, 
223. 

Semimembranosus,  tenotomy  of,  336. 

Semitendinosus,  tenotomy  of,  336. 


Senn's  bloodless  amputation  at  hip  joint, 
540;  method  of  injection  of  goitre,  722; 
operation  for  excision  of  head  of  hume- 
rus, 388. 

Sepis,  after  enucleation  of  tliyroid  body, 
717;  after  laminectomy,  311. 

Septic  part,  preparation  for  operation  of, 
95. 

Septum  nasi,  deviation  of,  661 ;  Post's  op- 
eration for,  662 ;  Wagner's  operation 
for,  602. 

Sequestrotomy,  358;  direct  method,  358; 
indirect  method,  301;  instruments  for, 
358;  on  clavicle,  880;  precautions  in  di- 
rect method  of,  358. 

Serous  surfaces,  needles  for,  99. 

Serre-lines,  77,  78. 

Serre's  method  of  stomatoplasty,  616. 

Sheath  of  a  vessel  as  a  guide  to  an  artery, 
125. 

Sheaths,  of  flexor  tendons  of  hand,  com- 
municability  of,  354;  tendon,  treatment 
of,  at  amputations,  468. 

Sheets,  clean  aseptic,  57. 

Shock,  120;  after  laminectomy,  311: 
Crile's  rubber  suit  for  shock,  122 ;  due 
to  loss  of  blood,  symptoms  of,  121;  in 
linear  craniotomy,  244;  operations  dur- 
ing, 4;  sinapisms  of  mustard  for,  121; 
prevention  of,  120;  treatment  of,  121; 
use  of  adrenalin  in,  67. 

Shoulder  joint,  amputation  above,  492; 
Berger's,  493;  comments  on,  494,  pre- 
cautions, 494;  results  of,  495. 

Shoulder  joint,  amputation  at,  486;  cir- 
cular-incision method,  489 ;  circular-in- 
cision method,  remarks  on,  489 ;  exter- 
nal- and  internal-flap  method,  Dupuy- 
tren's  488 ;  oval-flap  method,  Larrey's, 
491;  prevention  of  haemorrhage  in,  487; 
racket-flap  method,  Spence's,  491 ;  re- 
marks on,  492;  results  of,  492;  special 
considerations  for,  487;  Wj^eth's  needles 
in,  487. 

Shoulder  joint,  Kocher's  excision  of,  from 
behind,  390. 

Shrady's  saw,  434. 

Sick-room,  8. 

Silk  ligatures,  81,  85. 

Silk,  oiled,  as  a  dressing,  107. 

Silk  sutures,  97. 

Silkworm-gut,  85,  106. 

Silver  wire  sutures,  98,  102. 

Silvester's  method,  artificial  respiration, 
18. 

Simon's  operation  for  single  harelip, 
601. 

Simpson's  method  of  acupressure,  75. 

Sinapisms,  mustard,  during  shock,  121. 

Single  harelip,  600. 

Sinus,  frontal,  trephining  of,  265;  forma- 
tion in  operative  wound.  97 :  lateral, 
craniotomy  for  thrombosis  of,  260. 

Sinuses,  the  location  of.  237. 

Situation  usually  chosen  for  tapping  the 
ventricles,  227. 


XXX 


INDEX.    - 


Skey's  modification  of  Lisfranc's  tarso- 
metatarsal amputation,  504. 

Skin,  during  shock,  121;  flaps  in  ampu- 
tating, 452. 

Skin-grafting,  575;  Krause's  method, 
577;  Lusk's  (Z.  J.)  method,  577;  re- 
marks on,  577,  578;  Reverdin's  meth- 
od, 575;  Thiersch's  method,  576. 

Skinner's  inhaler,  30. 

Skull,  bony  landmarks  of,  245;  crani- 
otomy for  fracture  of,  231 ;  opening 
through,  for  cerebellar  tumor,  256. 

Smith's  (Stephen)  amputation  at  knee 
joint  for  gangrenous  condition  of  toes 
and  foot,  525. 

Smith's  modification  of  Lisfranc's  tarso- 
metatarsal amputation,  504. 

Snap-finger,  563. 

Soap  for  cleansing  the  hands,  114. 

Socin's  method  of  enucleation  of  goitre, 
718;  method  of  treating  oesophageal 
stricture,  674. 

Soda,  caustic,  in  jireparation  of  dressings, 
113;  washing,  in  preparation  of  dress- 
ings, 112. 

Sodium  carbonate,  for  cleansing  the 
hands,  114;  solutions  of,  62. 

Solutions,  aseptic  and  antiseptic,  59;  bin- 
iodide  of  mercury,  60;  boric  acid,  61; 
carbolic  acid,  59,  60;  corrosive  sub- 
limate, 59,  60,  61 ;  for  spinal  anesthe- 
sia, 41,  43;  iodine,  60;  saline,  62;  saline, 
injection  of,  221;  saturated,  of  iodo- 
form and  ether,  61;  sodium  carbonate, 
62;  sulpho-carbolate  of  zinc,  60;  sul- 
phurous acid,  61 ;  Thiersch's,  61 ;  zinc 
chloride,  60. 

Southerland's  method  of  drainage  of  lat- 
eral ventricles,  229. 

Spaces,  dead,  management  of,  101. 

Spasmodic  wryneck,  resection  of  spinal 
accessory  and  posterior  divisions  of 
cervical  nerves  for,  562. 

Special  emergencies  during  an  operation, 
120. 

Special   nerves,  operations   on,  276. 

Special  operations  on  nerves,  271. 

Spence's  method  of  excision  of  scapula, 
382;  racket-flap  method  of  amputation 
at  the  shoulder  joint,  491. 

Spiller  and  Frazer  method  of  intra- 
cranial division  of  trifacial  nerve, 
306. 

Spina  bifida,  317;  injections  of  iodoglyc- 
erin  solution  in,  317;  palliative  treat- 
ment of,  317;  radical  cure  of,  317;  re- 
sults of  injection  of  iodoglycerin  solu- 
tion in,  318;  treatment  of,  by  excision, 
318;  varieties  of,  317. 

Spinal  accessory  nerve,  319;  anatomical 
points  of,  319;  operations  on,  319; 
points  for  exposure,  319;  remarks  on 
operation  on,  320 ;  resection  of,  for  spas- 
modic wryneck,  562 ;  results  of  opera- 
tions on,  320. 

Spinal  anaesthesia,  41;  Morton's  method, 


43 ;  precautions  in,  42 ;  Tuffier's  method, 
42. 

Spinal  canal,  examination  of,  in  laminec- 
tomy, 312. 

Spinal  cord  and  spinal  nerves,  operations 
on,  311. 

Spinal  cord,  tumors  of,  319;  result  of  op- 
erations on,  319. 

Spinal  meningeal  drainage,  316;  anatom- 
ical points  for,  316. 

Spinal  nerves,  intraspinal  division  of  roots 
of,  321;  operations  on,  311. 

Spine,  curvature  of,  560;  curvature  of, 
treatment  with  plaster-of -Paris  jacket, 
Sayre's,  560 ;  of  Spix,  285 ;  supra-mea- 
tal,  as  a  guide  to  bony  meatus,  263. 

Splints,  nasal,  662. 

Sponge  on  holder  in  anaesthesia,  14. 

Sponges,  9,  57,  62 ;  assistant  to  count, 
94;  preparation  of,  63. 

Spontaneous  subclavian  aneurism,  Moy- 
nihan's  operation  on,  203;  remarks  on, 
and  results  of,  206. 

Square  knot,  83. 

Squire's  method  of  treating  "  birthmark," 
223. 

Stafi'ordshii'e  knot,  84. 

Stalls,  rubber  finger,   11-5. 

Staphyloplasty,  630;  Lane's  method,  631; 
Sehonborn's  operation  of,  630. 

Staphylorrhaphy,  620;  anaesthesia  in, 
620;  comments  on,  620;  muscular  in- 
fluence in,  621;  muscles  concerned  with, 
621;  position  of  patient  during,  620; 
remarks  on,  621;  results  of,  623;  Rose's 
position  for,  620;  steps  in  operation  of, 
622;  time  for,  620. 

Starr's  statistics  for  removal  of  brain  tu- 
mors, 255. 

Stay  knot,  Ballance  and  Edmunds's,  84. 

Sterilization  of  catgut.  Fowler's  method, 
87 ;  of  catgut.  Rice's  method,  87 ;  of 
gelatin.  Sailer's  method,  66;  of  instru- 
ments, 52,  112;  of  fabrics,  112;  of  silk 
ligatures,  85. 

Sterilizers,  portable  and  fixed,  52. 

Sterno-cleido  mastoid,  myotomy  of,  338; 
remarks  on  myotomy  of,   338. 

Sternum,  excision  of,  379;  results  of  ex- 
cision of,  379. 

Stimulants,  119;  in  anaesthesia,  14. 

Stokes's  cuneiform  osteotomy  for  relief 
of  talipes,  449;  modification  of  Gritti's 
amputation  of  thigh  through  condyles, 
529. 

Stomach,  examination  of,  during  gastrot- 
omy,  671. 

Stomatoplasty,  615;  Buck's  method,  615; 
Serre's  method,  616. 

Storage  batteries  for  galvano-cautery,  81. 

Stretching  of  the  great  sciatic  nerve, 
bloodless,  326. 

Stricture  of  oesophagus,  672;  comments 
on  operations  for,  676;  dilatation  of, 
672;  division  of,  with  string  friction, 
Abbe's  method,  675;   division  of,  with 


INDEX. 


XXXI 


string  friction,  author's  mctliod,  075; 
divuLsion  of,  074;  external  cx'sopluigot- 
omy  for,  074;  internal  oesopluigotomy 
for,  074;  malignant,  077;  results  of  op- 
erations for,  077;  results  of  tubage  in, 
078;  retrograde  dilatation  of,  073; 
treatment  after  operations  for,  077; 
tubage  in,  077. 

Strips,  gauze,  for  drainage,  100. 

Strychnine,  119,   122. 

Studdiford's  method  of  sterilizing  catgut, 
89. 

"Student's"  needle,  130. 

Stump,  qualities  of  a  good,  451. 

Styptic  collodion,  08. 

Stj'ptics,  08;  alum,  08;  hot  and  cold 
water  as,  08;  resin,  OS;  subsulphate  of 
iron  as,  08;  tannin,  OS. 

Susastragaloid  amputation,  heel-ilap 
method,  508;  Lingnerolles's  method, 
507 ;    Verneuil's  metliod,  508. 

Subastragaloid  dislocation,  500. 

Subclavian  artery,  anatomical  points  of, 
108;   guides  to,  108;    ligature  of,   108. 

Subclavian  artery,  first  portion,  left  side, 
guide  to,  108;  left  side,  ligature  of, 
108;  left  side,  relations  of,  109;  right 
side,  guide  to,  170;  right  side,  liga- 
ture of,  170;  right  side,  relations  of, 
170. 

Subclavian  artery,  second  portion,  liga- 
ture of,  174;  relations  of,  174. 

Subclavian  artery,  third  portion,  external 
jugular  vein  as  a  guide  to,  172;  liga- 
ture of,  171,  172;  linear  guide  to,  171; 
relations  of,  171. 

Subclavian  vein,  results  of  ligature  of, 
215. 

Subcutaneous  injection  of  saline  fluid, 
222;  ligaturing  of  ntevus,  224;  nerve 
section,  272. 

Subcutaneous  ligaturing  of  varicose  veins, 
210;  needle  for,  210;  precautions  in, 
210:  results  in,  217. 

Subcuticular  suture,  104. 

Subdural  haemorrhage,  238,  240;  opera- 
tion for,  241;   results  of,  241. 

Subfrontal  fissure,  249. 

Subhvoid  pharyngotomy,  092;  prognosis 
in,"093. 

Sublimate  solution  in  cleansing  tlie 
hands,  113. 

Submammary  infusion,  223. 

Submaxillary  nerve,  division  of,  279. 

Suboccipital  nerve,  320. 

Subperiosteal  removal  of  bone,  301. 

Subsulphate  of  iron,  as  a  styptic,  OS;  in- 
jection of  varicose  veins  with,  210. 

Suffocation  from  contents  of  stomach  dur- 
ing anaesthesia,  120. 

Sulpho-carbolate  of  zinc,  solutions  of,  GO. 

Sulphurous  acid,  01. 

Summary  of  preparations  for  operation, 
113. 

Superfrontal  fissure,  249. 

Superficial  palmar  arch,  incision  for,  191. 


Superior  maxilla*,  simultaneous  removal 
of,  372. 

Superior  maxillary  nerve, 278;  Carnochan- 
Chavasse  operation  on,  283;  dental 
branches  of,  279;  division  and  removal 
.  of,  279;  infra-orbital  portion,  279;  in- 
tra-cranical  portion,  279;  Kocher's  op- 
eration on,  281;  Lossen's  operation  on, 
284;  Liicke's  operation  on,  284;  opera- 
tion for  division  and  removal  of,  280; 
point  for  division  of,  279;  precautions 
for  operation  on,  280;  precautions  in 
C'arnochan-Chavasse  operation,  283;  re- 
marks on  Kocher's  operation  on,  281; 
remarks  on  operation  on,  280;  removal 
of,  279;  results  of  operation  on,  284; 
spheno-maxillarv  portion  of,  279; 
stretching  of,  279. 

Superior  thyroid  artery,  ligature  of,  197. 

Supernumerary  finger,  503. 

Suppuration,  relation  of,  to  scurvy,  0;  to 
glycosuiia,  5 ;   to  malaria,  0. 

Supramalleolar  amputation   of  leg,  516. 

Supra-maxillarj'  division  of  fifth  nerve, 
277. 

Supra-nieatal  spine  as  a  guide  to  bony 
meatus,  264. 

Supra-orbital   nerve,  operations  on,  276. 

Supra-renal  extract  as  an  haemostatic,  66; 
during  anaesthesia,  20. 

Supratrochlear  nerve,  operations  on,  277. 

Surgeon,  apparel  of,  115;  duty  of,  in  am- 
putations at  lower  extremity,  490;  re- 
hearsal of  steps  of  operation  by,  119; 
relation  of,  to  patient,  1. 

Surgeon's  knot,  82. 

Surgery,  plastic,  509. 

Surgical  cushion,  rubber,  54. 

Surgical  engine,  304. 

Surgical  needle,   76. 

Suture,  of  nerves,  272 ;  of  tendons,  338. 

Sutures,  buried,  103;  button,  103;  catgut, 
97 ;  celluloid  thread,  98 ;  chromicized 
catgut,  97;  classification  of,  97;  con- 
tinuous or  glover's.  102  :  deep.  98:  deep, 
to  control  bleeding,  90 ;  depth  of  and 
distance  between,  99;  difi'erent  forms 
of,  101;  for  three-cornered  wounds,  104; 
Halsted's  method  of  sterilizing  and  pre- 
serving, 90;  harelip,  102:  horsehair,  98; 
inorganic,  97,  98 ;  interrupted,  101 ; 
kangaroo  tendon,  97 ;  organic,  97 ;  pin, 
102;  quilled,  102;  relaxation  and  coap- 
tation, 104;  silk,  97;  silkworm-gut,  97; 
silver  wire,  98,  102 ;  subcuticular,  104 ; 
tension  of,  100;  time  for,  to  remain  iti 
situ,   100;   twisted,  102,   103. 

Suturing,  secondary,  101. 

Sylvius,  fissure  of,  location  of  (Reid),  247; 
posterior  limb  of,  250. 

Syme-Buchanan  method  of  clieiloplasty 
of  lower  lip,  009. 

Syme's  amputation  at  ankle  joint,  509; 
method  of  cheiloplasty  of  lower  lip, 
009:  modification  of  circular  integu- 
mentary-fiap  method  of  amputation  of 


xsxn 


INDEX. 


thigh,  535;  operation  of  rhinoplasty, 
581;  operation  of  rhinoplasty,  remarks 
on,  582. 

Sympathetic,  excision  of  the,  for  exoph- 
thalmic goitre,  Jaboulay  and  Jonnes- 
co's,  721. 

Syncope,  120;  during  antesthesia,  18; 
treatment  of,  18. 

Syndactylism,  563 ;  Agnew's  operation  for, 
566;  Dec's  operation  for,  564;  Diday's 
operation  for,  564;  Fowler's  operation 
for,  566;  Norton's  operation  for,  564; 
remarks  on,  567  ;  Rudtlorff  er's  operation 
for,  564;   Zeller's  operation  for,  566. 

Syndesmotomy,  348. 

Syringe,  fountain,  as  an  irrigator,  108 
Davidson's,  119;  hypodermic,  119 
Matas's,  for  infiltration  anesthesia,  39 
Pravaz's,  41. 

Szymanowski's  method  of  cheiloplasty  of 
upper  lip,  614;  saw,  419. 

Table,  operating,  9,  53,  113;  characteris- 
tics of  a  good,  54 ;  Cleveland's,  54 ;  Ede- 
bohls's,  56 ;  extemporized,  53  ;  Fowler's, 
55;  inclined  plane  for  use  in  conjunc- 
tion with,  56;  portable,  56;  preparation 
of  an,  53;   Pryor's,  56. 

Tablespoon  as  a  retractor,  129. 

Tablets  of  bichloride  of  mercury,  113. 

Tagliacotian  operation,  574. 

Talipes,  cuneiform  osteotomy  for  relief  of 
Bird's,  449;  cuneiform  osteotomy  for 
relief  of,  Stokes's,  449;  osteotomy  for 
447;  removal  of  astragalus  for  relief 
of,  Vogt's,  449;  excision  of  astragalo 
scaphoid  joint  for  relief  of,  Ogston's 
449. 

Talipes  equino-varus,  cuneiform  osteoto 
my  of  tarsus  for,  Davies-Colly,  447 
linear  osteotomy  of  neck  of  astragalus 
for,  Bradford's,  448;  linear  osteotomy 
of  neck  of  astragalus  for,  results  of 
448;  open  incision  for,  Phelps's,  448 
open  incision  for,  results,  449. 

Talipes  varus,  tibialis  anticus  in,  335 
tibialis  posticus  in,  332. 

Tamponing  of  trachea,  706;  Gerster'; 
method,  707;  Hahn's  method,  707 
Trendelenburg's  method,  707. 

Tannin  as  a  styptic,  68. 

Tapping  subarachnoid  space.  Parkin's  op 
eration  for,  316. 

Tapping  the  ventricles  for  acute  hydi'o 
cephalus,  229;  for  chronic  hydrocepha 
lus,  227;  for  paralysis  of  insane,  261. 

Tarsal  amputations,  irregular,  Molliere's 
506;  treatment  after,  "509;  results  of 
609. 

Tarsal  joints,  operations  on,  408. 

Tarsectomy  for  talipes  equino-varus 
Davies-Colly,  447;  results,  448. 

Tarso-metatarsal  joint,  amputation  at 
Baudens's,  504;  Key's,  504;  Lisfranc's 
502;   Skey's,  504;  Smith's,  504. 

Tarso-metatarsal  joint,  excision  of,  408. 


Tarsus,  cuneiform  osteotomy  of,  for  tali- 
pes equino-varus,  Davies-Colly,  447; 
excision  of  phalangeal  joints  of,  407; 
osteoplastic  resection  of  Wladimirow- 
Mikulicz,  415. 

Teale's  method  of  amputation  of  arm, 
485;  method  of  amputation  of  leg,  518; 
rectangular-flap    amputation,   458. 

Technique,  antiseptic,  in  gunshot  wounds 
of  the  cranium,  266;  aseptic  and  anti- 
septic, 94. 

Telephone  probe,  Girdner's,  267. 

Temporal  artery,  anatomical  points  of, 
201 ;  bony  guide  to,  201 ;  ligature  of, 
201. 

Temporal  bone  in  cerebral  abscess,  260. 

Tenaculum,  77,  78,  129;  in  amputating, 
467. 

Tendo  Achillis,  attachment  of,  409;  care 
after  tenotomy  of,  334;  lengthening  of, 
341 ;  lengthening  of,  by  Anderson's 
method,  341 ;  lengthening  of,  by  trans- 
plantation of  tubercle  of  os  calcis,  341 ; 
shortening  of,  342;  shortening  of,  Gib- 
ney's  method,  342;  shortening  of,  Wil- 
lett's  method,  343;  shortening  of,  Z 
method,  343;  tenotomy  of,  333. 

Tendon  anastomosis,  remarks  on,  345; 
anastomosis,  Vulpius's  operation,  345. 

Tendon  graft,  340. 

Tendon  lengthening,  340;  lengthening,  by 
accordeon  plan,  341 ;  lengthening,  by 
incision  method,  341 ;  lengthening,  by 
single  flap,  341. 

Tendon  sheaths,  treatment  of,  at  amputa- 
tions, 468. 

Tendon  shortening,  342 ;  remarks  on,  343. 

Tendon  sutures,  kangaroo,  97. 

Tendon  suturing,  338;  after  oblique  divi- 
sion, 340;  Billroth's  method,  340;  Hue- 
ter's  method,  340;  materials  for,  339, 
340;  methods  of,  340;  Nicoladoni's 
method,  340;  Witzel's  method  of,  340; 
Wolfler's  quilt  suture  in,  340. 

Tendon  transplantation,  343;  after  treat- 
ment of,  346 ;  choice  of  methods  in,  346 ; 
results  of,  346. 

Tendons,  retraction  of,  339;  sevei-ed  ends 
of,  in  amputations,  452. 

Tenorrhaphy,  338;  special  considerations 
of,  339. 

Tenosynovitis,  355. 

Tenotomes,  329. 

Tenotomy,  329;  instruments  employed  in, 
329;  of  lower  extremities,  332;  of  ad- 
ductor longus,  337;  of  biceps  flexor  cru- 
ris, 336;  of  biceps  flexor  cubite,  332;  of 
extensor  brevis  pollicis,  331 ;  of  extensor 
communis  digitorum,  331 ;  of  extensor 
longus  digitorum,  335;  of  extensor  lon- 
gus pollicis,  331 ;  of  extensor  ossis  meta- 
earpi  pollicis,  331;  of  extensor  proprius 
hallucis,  335 ;  of  flexor  carpi  radialis, 
331 ;  of  flexor  carpi  ulnaris,  331 ;  of 
flexor  longus  digitorum,  332;  of  flexor 
longus  digitorum,  precautions  in,  333; 


INDEX. 


XXXlll 


of  flexor  longus  poUicis,  333;  of  flexor 
profundus  digitorum,  331;  of  flexor 
sublimis  digitorum,  331;  of  flexor  sub- 
limis  digitorum,  precautions  in,  331;  of 
gracilis,  33G;  of  hamstrings,  33G;  of 
latissimus  dorsi,  337;  of  peroneus  bre- 
vis,  334;  of  peroneus  longus,  334;  of 
peroneus  tertius,  335  ;  of  quadriceps  ex- 
tensor, 337;  of  sartorius,  336;  of  semi- 
membranosus, 336 ;  of  semitendinosus, 
336;  of  tendo  Achillis,  333;  of  tibialis 
anticus,  335;  of  tibialis  posticus,  332; 
order  of  procedure  in,  330;  to  relieve 
flexed  leg,  remarks  on,  336;  upper  ex- 
tremities, 331. 

Tensile  strength   of  catgut,  87. 

Tension,  of  sutures,  100 ;  of  wound  when 
sewing,  99. 

Tensor  vaginas  femoris,  myotomy  of,  337. 

Testicle,  shock  due  to  injury  of,  120. 

Textile  fabrics,  sterilization  of,  112. 

Thecitis,  354;  acute,  355;  chronic,  352; 
operative  treatment  of,  354. 

Thermic  angiotripsy,  79. 

Thermo-cautery,  79 ;  in  bronchotomy,  690. 

Thiersch's  fluid,  61;  fluid  for  instruments, 
52;  gauze,  preparation  of.  111;  method 
of  skin-grafting,  576. 

Thigh,  amputation  of,  532;  Agnew's 
method  of  forming  flaps  in,  535 ;  antero- 
posterior musculo-integumentary-flap 
method,  534;  bilateral  flap  method, 
533;  circular  integumentary-flap  meth- 
od, 535 ;  equilateral-fiap  method,  Ver- 
male's,  533;  general  remarks  on,  537; 
long  anterior-  and  short  posterior-flap 
method,  Farabeuf's,  537  ;  long  anterior- 
flap  method,  Sedillot's,  537 ;  methods  of, 
533 ;  single  circular-incision  method, 
Celsus's,  536;  results  of,  540;  special 
considerations  for,  532;  suturing  over 
the  end  of  bone  after,  537 ;  Syme's  modi- 
fication of  circular  integumentary-flap 
method,  535 ;  through  trochanters,  540 ; 
treatment  after,  539. 

Thigh,  amputation  of,  through  condyles, 
528;  Garden's  method,  528;  Garden's 
method,  results  of,  528;  fallacies  of 
Gritti's  method,  529;  Farabeuf's  modi- 
fication of  Garden's  method,  529 ;  Grit- 
ti's method,  529;  Lister's  modification 
of  Garden's  method,  528;  results  of 
Stokes's  and  Gritti's  methods,  530;  Sa- 
banejeff's  osteoplastic  method,  532; 
Stokes's  modification  of  Gritti's  method, 
529. 

Thoracic  duct,  injury  of,  730;  in  ligature 
of  the  t,ubclavian,  left  side,  first  portion, 
170. 

Thoracic  injury,  shock  due  to,  120. 

Thread  suture,  celluloid,  98. 

Three-cornered  wound  suture,  104. 

Throat  forceps,  664. 

Thrombosis    after    craniotomy,    244;    of 
lateral  sinus  and  jugular  vein,  craniot- 
omy for,  260. 
50 


Thumb,  amputation  of,  at  carpo-meta- 
carpal  articulation,  473. 

Thumb  forceps,  46,  129. 

Thymol,  62. 

Thyroid  artery,  inferior,  anatomical 
points  of,  177;  inferior,  guide  to,  linear, 
177;  inferior,  ligature  of,  177;  superior, 
anatomical  points  of,  197;  superior, 
ligature  of,  197. 

Thyroid  body,  comments  on  partial  enu- 
cleation of,  716;  dangers  of  operations 
on,  722;  dressing  of  wound  after  opera- 
tions on,  723;  enucleation  of,  717,  718; 
enucleation  resection  of,  Kocher's, 
717;  in  ligature  of  common  carotid, 
193;  operations  on,  710;  operations  on, 
anatomical  points  for,  710;  partial  ex- 
cision of,  Kocher's,  711;  partial  excision 
of,  Kocher's,  remarks  on,  714;  partial 
excision  of,  precautions  in,  715;  partial 
excision  of,  through  angular  incision, 
714;  preparation  of  patient  for  opera- 
tions on,  711;  results  of  operation  on, 
722;  treatment  after  operation  on,  722. 

Thyroid  cartilage,  681. 

Thyroidectomy,  Kocher's,  719;  remarks 
on,  720. 

Thyi'otomy,  685,  689;  instruments  for, 
683;  precautions  in,  690;  remarks  on, 
690. 

Tibial  artery,  anterior,  anatomical  points 
of,  150;  anterior,  ligature  of,  150;  an- 
terior, linear  guide  to,  151;  anterior, 
muscular  guide  to,  151;  posterior,  ana- 
tomical points  of,  153;  posterior,  liga- 
ture of,  153 ;  posterior,  linear  guide 
to,  154;  posterior,  muscular  guide  to, 
154. 

Tibial  nerves,  anterior  and  posterior,  ex- 
posure of,  327. 

Tibialis  anticus  in  talipes  varus,  335; 
tenotomy  of,  335. 

Tibialis  posticus  in  talipes  varus,  332; 
tenotomy  of,  332. 

Tissue,  rubber,  as  a  dressing,   107. 

Tissues,  separation  of,  in  ligature  of  ar- 
teries, 127 ;  uniting  of  divided,  98. 

Time  in  the  prevention  of  shock,  121. 

Toe,  great,  amputation  of,  498;  by  inter- 
nal plantar-flap  method,  Farabeuf's, 
499;  by  oval-flap  method,  499;  by 
square-flap  method,  498 ;  first  phalanx 
of,  496,  497 ;  with  metatarsal  bone,  501 ; 
through  last  phalanx  of,  497. 

Toe,  great,  excision  of  mctatarso-phalan- 
geal  joint  of,  408. 

Toe,  little,  amputation  of,  498;  by  inter- 
nal plantar-flap  method.  Farabeuf's, 
499;  by  oval  flap  method,  499;  with 
metatarsal  bone,  501. 

Toe-nail,  ingrown.  567  ;  Anger's  operation 
for,  567;  Cotting's  operation  for,  568; 
results  of  operation  for,  568. 

Toes,  amputation  of,  497 ;  amputation  of 
two  adjoining,  499;  removal  of  second, 
third,  or  fourth,  497. 


XXXIV 


INDEX. 


Tongue,  choice  of  method  in  removal  of, 

643;     control    of    hiemorrhage    during 

operation    on,     Langenbeck's    method, 

634. 

Tongue,    excision    of,    methods    of,    635; 

"  V  "-shaped  incision  foi",  635. 
Tongue  forceps,  13,  119. 
Tongue,  Hueter's  operation  on,  638. 
Tongue,  hypertrophy  of,  637. 
Tongue,  operations  on,  634;  laryngotomy 

preliminary  to,  635. 
Tongue,  removal  of,  Billroth's  method, 
642;  entire,  methods  of,  638;  entire, 
through  mouth,  638;  entire,  through 
mouth,  treatment  after,  639;  general 
remarks  on,  643 ;  Jaeger's  method,  641 ; 
Kocher's  method,  639;  Langenbeck's 
method,  642 ;  one-half  of,  637 ;  one-half 
of,  comments  on,  638 ;  Regnoli's  method, 
642;  results  of,  643;  treatment  after, 
643;  when  floor  of  mouth  is  involved, 
642;  with  division  of  jaw,  Sedillot's 
method,  640;  with  ecraseur,  641. 
Tongue-tie,  644. 

Tonsil,  abscess  of,  634;   excision  of,  633; 
excision  of,  results  of,  634;  removal  of, 
with  knife  and  scissors,  633. 
Tonsil  and  pillar  of  fauces,  tumor  of,  re- 
moval  of,   644;    anatomical   points  of, 
644. 
Tonsillotomes,  633. 
Tonsils,  relations  of,  to  internal   carotid 

artery,  196. 
Torsion  as  an  haemostatic,  76. 
Torsion  forceps,  76. 
Torsoclusion,  76. 

Torticollis,  561;    spasmodic,   resection   of 
spinal    accessory    and    cervical    nerves 
for,  562 ;  treatment  of,  by  open  method, 
561;  treatment  of,  by  open  method,  re- 
sults of,  562. 
Tourniquet    for    compressing    abdominal 
aorta,    540;    Esmarch's,    541;    Lister's, 
541 ;  Pancoast's,  541. 
Tourniquet,  extemporized,  72;  Petit's,  72. 
Towels,  clean  aseptic,  57. 
Toxic  dose  of  adrenalin,  67. 
Trachea    aspirator,    684;    dilators,    683; 
foreign  body  in,  698 ;  general  comments 
on  operations  on,   690;    operations   on, 
treatment  after,  692;  operations  on,  re- 
sults   of,    692;    size   of,    in   adult,   681; 
tamponing,  706;  tube,  bivalve,  683. 
Tracheotomy,    above    the    isthmus,    688; 
anatomical  points  for,  687 ;  below  isth- 
mus,  687;    high,  687;   instruments  for, 
683 ;   low,  687 ;   preliminary  to  excision 
of,  upper  jaw,  365;   preliminaiy  to  re- 
moval of  entire   tongue,   639 ;    prelimi- 
nary to  removal  of  nasal  growth,  657, 
660;   situations  for,  687;  through  isth- 
mus, 689;  tube,  119. 
Traction  loops,  50,  129,  130. 
Transfixion  flaps,  453. 
Transfusion,  apparatus  for,  220;    during 
operation,   119;   point  for  introduction 


of,  220;  saline,  Dawbarn's  method,  221; 
solutions  used  for,  220. 

Transperitoneal  ligature  of  the  common 
iliac  artery,  132;  of  internal  iliac  ar- 
tery, 135. 

Transplantation,  of  bone,  450 ;  of  tubercle 
of  OS  calcis  in  lengthening  tendo  Achil- 
lis,  341 ;  of  tubercle  of  os  calcis  in  short- 
ening tendo  Achillis,  343. 

Transverse   fissure    (brain),  248. 

Ti-apezius,  myotomy  of,  338. 

Traumatic  aneurism,  extirpation  of,  202; 
aneurism,  results  of,  203. 

Traumatic  epilepsy,  results  of  operations 
for,  257. 

Treatment  of  brain  tumor,  253 ;  of  opera- 
tion wounds,  96. 

Trendelenburg's  apparatus  for  adminis- 
tration of  anaesthetic  through  tracheot- 
omy tube,  660;  apparatus  for  anaesthe- 
sia, extemporized  substitutes  for,  660; 
method  of  meloplasty,  617;  method  of 
tamponing  the  trachea,  707;  operation 
for  goitre,  721;  operation  for  varicose 
veins,  217;  posture  in  laryngotomy, 
690 ;  posture  in  ligation  of  common  iliac 
artery,  133;  posture  in  ligation  of  ex- 
ternal iliac  artery,  139 ;  posture  in  liga- 
tion of  internal  iliac  artery,  135;  rod, 
74;  rod,  use  of,  in  amputations  at  hip 
joint,  542. 

Trephine,  passage  of,  through  diploe,  234. 

Trephines,  circular  or  crown,  231 ;  conical 
or  Gait,  231. 

Trephining,  cranium,  231;  frontal  sinus, 
265;  frontal  sinus,  precautions  for,  266; 
over  important  vessels,  237. 

Treves's  method  of  complete  laryngectomy, 
701;  operation  on  cervical  lymphatic 
glands,  729;  operation  on  cervical  lym- 
phatic glands,  precautions  in,  729;  op- 
eration on  cervical  lymphatic  glands, 
remarks  on,  730. 

Trifacial  nerve,  anatomical  points  of 
trunk  of,  at  foramen  ovale,  290;  guide 
to,  in  intracranial  neurectomy,  300; 
Horsley's  intradural  division  of,  307 ; 
Mixter's  operation  on,  at  base  of  skull, 
293;   Mixter's  operation,  comments  on, 

'  294;  operations  applicable  to  first  and 
second  portions  and  to  Meckel's  gan- 
glion, 281 ;  operations  on  first  division 
of,  276;  operations  on  second  division 
of,  277;  precautions  in  operations  on, 
at  base  of  skull,  294;  results  of  opera- 
tions on,  at  base  of  skull,  294;  Spiller 
and  Frazer  method  of  intracranial  di- 
vision of,  306;  third  division  of,  284; 
treatment  after  operations  on,  at  base 
of  skull,  294;  trunk  of,  at  foramen 
ovale,  290. 

Trifacial  nerve,  intracranial  neurectomy 
of,  295;  Abbe's  method,  306;  Cushing's 
method,  303;  Doyen's  method,  302; 
Hartley-Krause  method,  296;  Eose's 
method,  295. 


INDEX. 


XXXV 


Trifacial  nerve,  operation  on,  at  foramen 
ovale,  Crede's,  2U3;  Kocher's,  202; 
Kronlein's,  293;  Pancoast's,  293;  Sal- 
zer's,  293. 

Tripier's  amputation  through  the  os 
calis,  508. 

Trochanter,  great,  excision  of,  425. 

Trochanters,  amputation  of  thigh 
through,   540. 

Tube,  trachea,  bivalve,  083;  tracheotomy, 
119. 

Tubercle  bacilli  in  thecitis,  354. 

Tubes,  drainage,  removal  of,  106 ;  Neu- 
ber's  decalcified,  for  drainage,  106. 

Tubing,  rubber,  for  drainage,  105. 

Tuffier's  method  for  inducing  spinal  anes- 
thesia, 42. 

Tumor,  brain,  craniotomy  for,  245 ;  brain, 
treatment  of,  253;  cerebellar,  craniot- 
omy for,  255;  due  to  dilatation  of  capil- 
laries, 223;  of  spinal  cord,  319;  of 
spinal  cord,  result  of  operations  on,  319; 
of  tonsil  and  pillar  of  fauces,  removal 
of,  644. 

"Tupfers,';  63,  64. 

Turnipseed's   amputation  of  foot,  514. 

Twisted  suture,  102,  103. 

Ulna,  excision  of,  399. 

Ulnar  artery,  anatomical  points  of,  188 ; 
guides  to,  188;  ligature  of,  188;  points 
for  ligature  of,  189;  relations  of,  188. 

Ulnar  nerve,  displacement  of,  324;  situa- 
tions for  exposure  of,  324. 

Union  by  first  intention,  97. 

Upper  extremity,  amputation  at,  468;  in 
female  subject,   185. 

Uranoplasty,  623;  comments  on,  629; 
Davies-Golly  method,  626 ;  Dieffen- 
bach-Fergusson  method,  625;  Fergus- 
son's  method,  626;  Langenbeck's  meth- 
od, 623;  Lannelongue's  method,  625; 
results  of,  630;  treatment  after,  629. 

Urine,  examination  of,  after  operation, 
118;  suppression  of,  after  anaesthesia, 
21. 

Uvula,  elongated,  631. 

Van  Bergmann's  method  of  preparing  cat- 
gut, 91. 

Van  Buren's  operation  for  salivary  fistula, 
632. 

Varicose  veins,  operative  interference  by 
acupressure,  216;  operative  interference 
by  injection  for,  216;  excision  of  a  por- 
tion of  the  saphenous  vein  for  (Fergus- 
son),  218;  incision  around  leg  for 
(Schede),  218;  ligature  of  the  internal 
saphenous  vein  for  (Trendelenburg), 
217;  operations  on,  215;  subcutaneous 
ligaturing  of,  216;  treatment  of.  by  in- 
cision and  ligaturing,  217;  treatment 
of,  by  excision.  217. 

Varnish,  antiseptic,  "WTiitehead's,  639. 

Vascular  growth,  introduction  of  setons 
into,  225. 


Vascular  guides  to  an  artery,  125. 

Vaso-motor  center  in  collapse,  120;  in 
shock,  120. 

Vein,  companion  to  large  arteries,  125; 
external  jugular,  as  a  guide  to  the  third 
portion  of  the  subclavian,  172;  jugular, 
craniotomy  for  thrombosis  of,  260. 

Veins,  air  in,  122;  and  capillaries,  opera- 
tions on,  215;  color  of,  126;  ligature 
of,  215;  relation  of,  to  arteries,  126; 
varicose,  operations  on,  215. 

Velpeau's  incision  for  complete  excision 
of  upper  jaw,  368. 

Venae  comites,  125;  ligature  of,  with  ar- 
tery, 153. 

Venesection,  218;  amount  of  blood  taken 
in,  219;  arrest  of  blood  flow  after,  219; 
at  external  jugular,  219;  at  median 
cephalic,  218;  instruments  for,  218;  se- 
lection of  veins  for,  218. 

Venous  infusion,  precautions  for,  221 ; 
the  operation  of,  220. 

Ventricles,  injection  of  saline  solution 
into,  228 ;  tapping  of  the,  for  chronic 
hydrocephalus,  227. 

Vermale's  amputation  of  thigh,  equilat- 
eral-flap method,  533. 

Verneuil's  operation  of  rhinoplasty,  585; 
operation  of  rhinoplasty,  remarks  on, 
586;   subastragaloid  amputation,  508. 

Vertebral  artery,  anatomical  points  of, 
174;  linear  guide  to,  175;  muscular 
guide  to,  175;  points  for  ligature  of, 
175;  relations  of,  174. 

Vertebral  artery,  ligature  of,  174;  Alex- 
ander's method,  176;  before  entering 
vertebral  canal,  175;  between  atlas  and 
axis,  176;  between  atlas  and  occipital 
bone,  177;  precaution  in,  176. 

Vertical  frontal  fissure,  249. 

Vessel,  closure  of,  en  masse,  96;  opening 
sheath  of,  127 ;  selection  of,  for  ligature, 
126, 

Vessels,  color  of,  as  a  guide  to  an  artery, 
125;  empty,  9,  57;  healthy  condition 
of,  as  haemostatic,  65. 

Vogt's  excision  of  ankle  joint,  413. 

Volkmann's  division  of  neck  of  femur, 
437:  division  of  neck  of  femur,  results 
of,  437  ;  inter-trochanteric  osteotomy  of 
femur,  438. 

Vomiting  after  anaesthesia,  20. 

"Washing  soda  in  preparation  of  dressings, 

112. 
Water,  as  a  local  anaesthetic,  36;  boiled, 

as  a  menstruum,  62;  hot  and  cold,  as 

styptics.  68. 
Wax,  Horsley's,  236. 
Webbed  fingers,  563 :  remarks  on,  567. 
Webbed    fingers,   operation    for,    Agnew's, 

566;  Dec's^  564;  Diday's.  564;  Fowler's. 

566;    Norton's,  564;  Rudtlorffer's,  564- 

Zeller's,  566. 
Webber's    incision    for    raising    superior 

maxilla,  660. 


XXXVl 


INDEX. 


Weber's  method  of  flap  transfer  in  plastic 
surgery,  574;  operation  of  rhinoplasty, 
583. 

Weeping  sinew,  352. 

Weir's  method  of  cleansing  the  hands, 
114. 

Whalebone  tissue  ligatures,  93. 

Whiskey,  119;  in  shock,  121;  with  anses- 
thetics,  35. 

White's  radical  excision  of  hip  joint,  426. 

Whitehead's  antiseptic  varnish,  639. 

Willett's  method  of  shortening  the  tendo 
Achillis,  343. 

"Wipers,"  63;  relation  of,  to  surgeon,  64. 

Wire  saw,  Gigli-Haertel,  243. 

Wire  serre-fines,  78. 

Wire  sutures,  silver,  98,  102. 

Witzel's  method  of  tendon  sutui'ing,  340. 

Wladimirow-Mikulicz,  osteoplastic  resec- 
tion of  tarsus,  415. 

Wolff''s  artificial  larnyx,  708. 

Wolfler's  quilt  suture  in  tendon  suturing, 
340. 

Wood-pulp  dressing,  112. 

Wood-wool  dressing,  112. 

Wound,  closure  of  a,  99;  drainage  of, 
104;  dressing  of,  after  operation  on  thy- 
roid, 723;  douching  of,  108;  treatment 
of,  after  operation,  118. 

Wounds,  gunshot,  of  the  cranium,  266; 
of  neck,  723;  of  neck,  treatment  of, 
724;  treatment  of  operation,  96. 

Wright  on  use  of  calcium  chlorid  in 
haemophilia,  67. 


Wrist  oint,  amputation  at,  477 ;  circular- 
flap  method,  477 ;  double-flap  method, 
Ruysch's,  478;  radial  flap,  Dubrueil's, 
479;  remarks  on,  479;  results  of,  479; 
single  palmar  flap,  478. 

Wrist  joint,  excision  of,  400;  excision  of, 
complete  subperiosteal,  Langenbeck's, 
402;  complete  subperiosteal.  Lister's, 
404;  complete  subperiosteal,  Ollier's, 
403. 

Wryneck,  561 ;  spasmodic,  resection  of 
spinal  accessory  and  cervical  nei-ves 
for,  562;  ti'eatment  by  open  method, 
561 ;  treatment  by  open  method,  re- 
marks on,  562. 

Wyeth's  amputation  at  ankle  joint,  511; 
method  of  controlling  haemorrhage  in 
amputations  at  the  hip,  542 ;  method 
of  treating  vascular  growths,  226; 
needles  in  amputation  at  shoulder  joint, 
487;  pegs  after  excision  of  knee  joint, 
422;   pin,  75. 


X  "  rays,  location  of  bullet  by,  267. 


"  Z  "  method  of  shortening  tendo  Achillis, 

343. 
Zeller's  operation  for  webbed  fingers,  566. 
Zinc  chloride,  solutions  of,  60. 
Zinc,  sulphocarbolate,  solutions  of,  60. 
Zuckerkandl's   extrabuccal    operation   on 

buccal  nerve,  290. 


(1) 


THE  SURGICAL  DISEASES 

OF  THE  GENITO-URINARY 

ORGANS. 

NEU^  SECOND  EDITION,  REVISED  AND  ENLARGED 
By  E.  L  KEYES,  A.M.,  M.D.,  LLD. 

Consulting  Surgeon  to  the    Bellevue    and  the  Skin   and   Cancer   Hospitals  ;    formerly 

Professor  of  Genito-Urinary  Surgery,  Syphilology,  and  Dermatology 

at  the  Bellevue  Hospital  Medical  College,  etc. ;  and 

E.  L.  KEYES,  JR.,.A.B.,  M.D.,  Ph.D., 

Adjunct  Professor  of  Genito-Urinary  Surgery,  New  York  Polyclinic  Medical  School  and 

Hospital  ;  Assistant  V'siting  Surgeon  to  St.  Vincent's  Hospital  ;  Special  Lecturer 

on  Genito-Urinary  Diseases,  Georgetown  University  Medical  School,  etc. 

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'Treatment  of  Urethral  Inflammation  and  their  Immediate  Complications.'  " — Canada 
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ticular."— Cincinnati  Lancet-Clinic. 

D.     APPLETON     AND     COMPANY,     NE^V    YORK. 


DISEASES  OF  THE  HEART 
AND  ARTERIAL  SYSTEM 

By  ROBERT  H.  BABCOCK,  A.M.,  M.D. 

Professor   of  Clinical    Medicine    and    Diseases   of  the    Chest,    College    of    Physicians 

and    Surgeons    (Medical    Department   of    the    Illinois   State    University), 

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but  it  is  open  to  question  whether  the  conclusions  and  results  of  a  ripe  judgment,  such 
as  are  presented  in  this  volume,  are  not  worth  quite  as  much  as  some  academic  so- 
called  original  work.  Certainly  a  large  amount  of  material,  both  clinical  and  literary, 
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CANCER  OF  THE 
UTERUS: 

Its  Pathology,  Symptomatology,   Diagnosis,  and   Treatment  ;    also 
the  Pathology  of  the  Diseases  of  the  Endometrium. 

By  THOMAS   STEPHEN   CULLEN,    M.  B. 

(Toronto),   Associate  Professor  of  Gynecology  in  the  Johns  Hopkins  University. 

Illustrated   by   MAX   BRODEL   and   HERMAN   BECKER. 

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to  the  family  physician,  and  to  the  surgeon.  The  chapters  on  the 
early  recognition  of  cancer  are  so  distinct  and  clear  that  a  wayfaring 
man,  though  a  general  practitioner,  should  not  err  in  giving  or  di- 
recting prompt  and  efficient  relief." — Medical  News,  New  York. 

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"We  know  that  the  Baltimore  school  of  medicine  has  carried 
the  utilization  of  clinical  and  scientific  material  almost  to  perfection, 
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features  of  the  different  varieties  of  uterine  cancer  and  of  innocent 
disease  which  simulate  it  are  described  very  clearly  so  that  Dr. 
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ist and  the  teacher  of  pathology." — British  Medical  Journal. 

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cancer  of  the  uterus,  and  we  may  say  at  once  that  as  a  monograph 
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who  wishes  to  be  well  informed  on  the  subject  of  cancer  of  the 
uterus  can  afford  to  be  without  it." — Medical  Press  and  Circular, 
London. 

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DISEASES   OF   THE    ANUS,    RECTUM, 
AND  PELVIC  COLON. 

SECOND  REI^ISED   AND   ENLARGED    EDITION. 

By  JAMES  P.  TUTTLE,  A.M.,  M.D. 

Professor  of  Rectal  Surgery,  New  York  Polyclinic  Medical  School  and  Hospital  ;  Visiting 

Surgeon  to  the  Almshouse  and  Workhouse  Hospital  ;    Fellow  of  New  York 

Academy  of  Medicine  ;  Fellow  of  Chicago  Academy  of  Medicine,  etc. 

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so  much  anticipation  as  this  work  of  Dr.  Tuttle.  Not  only  has  the  author  gained  an 
enviable  national  reputation  as  a  specialist  in  his  chosen  field,  but  he  is  widely  known 
also  as  a  successful  teacher  in  this  comparatively  new  specialty.  Great  expectations  are 
apt  to  meet  with  disappointment,  but  in  this  instance  there  is  a  marked  exception. 
The  book  is  almost  encyclopedic  in  the  amount  of  information  it  contains,  and  yet  the 
information  is  presented  in  a  concise  and  attractive  style.  The  illustrations  in  the  book 
are  on  a  high  plane  of  artistic  merit;  they  are  readily  understood,  and  are  also  in- 
structive. The  work  is  destined  to  become  the  authority  on  this  subject  for  both  the 
specialist  and  the  general  practitioner." — The  New  York  State  Journal  of  Medicine. 

"  This  volume  deals  with  one  of  the  most  important  departments  of  medicine  and 
surgery,  and  one  which  is  progressively  attracting  more  and  more  attention.  A  long 
experience  in  one  of  the  largest  rectal  clinics  in  the  world  has  peculiarly  fitted  the  author 
to  discuss  the  subject  in  an  exhaustive  manner.  While  in  great  measure  the  volume 
reflects  the  personal  experience  of  the  author,  much  attention  is  nevertheless  given  to 
the  ideas  and  results  of  other  operators,  and  in  every  instance  the  reader  is  afforded  an 
opportunity  to  choose  between  the  different  methods  of  management  or  treatment  pro- 
posed. It  is  by  no  means  exclusively  a  surgical  work,  for  much  attention  is  devoted 
to  the  medical  management  of  the  diseases  of  the  anus,  rectum,  and  pelvic  colon.  A 
great  deal  of  attention  has  been  devoted  to  the  examination,  diagnosis,  and  local  treat- 
ment of  rectal  diseases,  and  the  chapters  devoted  to  these  subjects  are  nowhere  excelled 
in  the  English  language;  chapters  which  every  practising  physician  and  surgeon  could 
and  should  read  with  much  profit,  for  in  no  department  of  medical  science  is  the  gen- 
eral practitioner  more  lamentably  weak  than  in  the  examination,  diagnosis,  and  manage- 
ment of  rectal  disorders." — Medical  News. 

"We  are  pleased  to  observe  that  medical  as  well  as  surgical  treatment  has  received 
the  most  painstaking  consideration,  and  the  treatise  is  a  remarkably  well-balanced  one. 
The  embryology,  anatomy,  and  physiology  of  the  parts  concerned  are  discussed  with 
thoroughness  and  clearness,  and  the  text  is  further  enlightened  by  the  beautifully  exe- 
cuted drawings  to  which  we  have  referred.  The  subject  of  rectal  feeding  is  discussed 
with  full  regard  for  the  practical  side.  The  author  has  included  a  large  number  of  care- 
fully selected  formulas  for  rectal  feeding.  In  our  opinion  the  chapters  devoted  to  the 
consideration  of  malignant  neoplasms,  containing  as  they  do  the  most  accurate  and 
clear  description  of  operative  procedures,  are  worthy  of  the  highest  praise.  No  less  ad- 
mirable is  the  somewhat  brief  but  well-presented  discussion  of  constipation,  obstipation, 
and  fecal  impaction." — The  Thiladelphia  Medical  journal. 

D.    APPLETON     AND     COMPANY,    NEW     YORK. 


i 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  32  684  1905  C.I 

Operative  surqi;iv 


2002187663 


RD32 


Bryant 


nnpffl+.Tvfi    Rijrt'ftfV. 


B84 

1905 
v.l 


